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Anorexia Nervosa

Signs, Symptoms, Causes, and Treatment

Girl eating cucumber

Many of us wish we looked different or could fix something about ourselves. That’s only human. But if a preoccupation with being thin has taken over your eating habits, thoughts, and life, you may have an eating disorder. When you have anorexia, the desire to lose weight becomes more important than anything else. You may even lose the ability to see yourself as you truly are. But you’re not alone and recovery is possible. With the right treatment and support, you can break anorexia’s self-destructive pattern and regain your health and self-confidence.

What is anorexia nervosa?

Anorexia nervosa is a serious eating disorder that results in unhealthy, often dangerous weight loss. While it is most common among adolescent women, anorexia can affect women and men of all ages and is characterized by a refusal to maintain a healthy body weight, an intense fear of gaining weight, and a distorted body image.

In today’s image-obsessed culture, many of us worry about putting on weight, but if you have anorexia, you’ll go to extreme lengths to maintain a low weight. You may try to lose weight by starving yourself, exercising excessively, or using laxatives, vomiting, or other methods to purge yourself after eating. Thoughts about dieting, food, and your body may take up most of your day—leaving little time for friends, family, and other activities you used to enjoy. Life becomes a relentless pursuit of thinness and intense weight loss. But no matter how skinny you become, it’s never enough.

  • Restricting type of anorexia is where weight loss is achieved by restricting calories (following drastic diets, fasting, exercising to excess).
  • Purging type of anorexia is where weight loss is achieved by vomiting or using laxatives and diuretics.

The intense dread of gaining weight or disgust with how your body looks, can make eating and mealtimes very stressful. And yet, food and what you can and can’t eat is practically all you can think about. But no matter how ingrained this self-destructive pattern seems, there is hope. With treatment, self-help, and support, you can break the hold anorexia has over you, develop a more realistic body image, and regain a healthier balance in your life.

Are you anorexic?

  • Do you feel fat even though people tell you you’re not?
  • Are you terrified of gaining weight?
  • Do you lie about how much you eat or hide your eating habits from others?
  • Are your friends or family concerned about your weight loss, eating habits, or appearance?
  • Do you diet, compulsively exercise, or purge when you’re feeling overwhelmed or bad about yourself?
  • Do you feel powerful or in control when you go without food, over-exercise, or purge?
  • Do you base your self-worth on your weight or body size?

Anorexia is a spectrum

There’s a substantial gray area between healthy eating and full-blown anorexia. While about 1 in 200 adults are diagnosed with anorexia, many more of us have exhibited key symptoms, such as purging, exercising compulsively, or trying extreme diet after extreme diet. Disordered eating that falls outside the criteria of an anorexia diagnosis can still cause major distress and be just as devastating as the full-blown disorder. Acting early may prevent your condition from escalating. So even if you don’t meet the specific criteria to be diagnosed with anorexia, that doesn’t mean that your situation is not serious or you’re not worthy of help.

Source: Almost Anorexic

Signs and symptoms of anorexia

While people with anorexia often exhibit different habits, one constant is that living with anorexia means you’re constantly hiding those habits. This can make it hard at first for friends and family to spot the warning signs. When confronted, you might try to explain away your disordered eating and wave away concerns. But as anorexia progresses, people close to you won’t be able to deny their instincts that something is wrong—and neither should you. If eating and weight control your life, you don’t have to wait until your symptoms have progressed or your health is dangerously poor before seeking help.

Food behavior symptoms

Dieting despite being thin – Following a severely restricted diet. Eating only certain low-calorie foods. Banning “bad” foods such as carbohydrates and fats.

Obsession with calories, fat grams, and nutrition – Reading food labels, measuring and weighing portions, keeping a food diary, reading diet books.

Pretending to eat or lying about eating – Hiding, playing with, or throwing away food to avoid eating. Making excuses to get out of meals (“I had a huge lunch” or “My stomach isn’t feeling good”).

Preoccupation with food – Constantly thinking about food. Cooking for others, collecting recipes, reading food magazines, or making meal plans while eating very little.

Strange or secretive food rituals – Refusing to eat around others or in public places. Eating in rigid, ritualistic ways (e.g. cutting food “just so," chewing food and spitting it out, using a specific plate).

Appearance and body image symptoms

Dramatic weight loss – Rapid, drastic weight loss with no medical cause.

Feeling fat, despite being underweight – You may feel 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 – Spending a lot of time in front of the mirror checking for flaws. There’s always something to criticize. You’re never thin enough.

Denial that you’re too thin – You may deny that your low body weight is a problem, while trying to conceal it (drinking a lot of water before being weighed, wearing baggy or oversized clothes).

Purging symptoms

Using diet pills, laxatives, or diuretics – Abusing water pills, herbal appetite suppressants, prescription stimulants, ipecac syrup, and other drugs for weight loss.

Throwing up after eating – Frequently disappearing after meals or going to the bathroom. May run the water to disguise sounds of vomiting or reappear smelling like mouthwash or mints.

Compulsive exercising – Following a punishing exercise regimen aimed at burning calories. Exercising through injuries, illness, and bad weather. Working out extra hard after bingeing or eating something “bad.”

Anorexia causes and effects

There are no simple answers to the causes of anorexia. Anorexia is a complex condition that arises from a combination of many social, emotional, and biological factors. Although our culture’s idealization of thinness plays a powerful role, there are many other contributing factors, including:

  • Body dissatisfaction
  • Strict dieting
  • Low self-esteem
  • Emotional difficulties
  • Perfectionism
  • Troubled family relationships
  • History of physical or sexual abuse
  • Other traumatic experiences
  • Family history of eating disorders

Effects of anorexia

While the causes of anorexia are uncertain, the physical effects are clear. When your body doesn’t get the fuel it needs to function normally, it goes into starvation mode and slows down to conserve energy. Essentially, your body begins to consume itself. If self-starvation continues and more body fat is lost, medical complications pile up and your body and mind pay the price.

Distracted woman eating

Source: National Women's Health Information Center

Getting help

Deciding to get help for anorexia is not an easy choice to make. It’s not uncommon to feel like anorexia is part of your identity—or even your “friend.” You may think that anorexia has such a powerful hold over you that you’ll never be able to overcome it. But while change is hard, it is possible.

Admit you have a problem. Up until now, you’ve been invested in the idea that life will be better—that you’ll finally feel good—if you lose more weight. The first step in anorexia recovery is admitting that your relentless pursuit of thinness is out of your control and acknowledging the physical and emotional damage that you’ve suffered because of it.

Talk to someone. It can be hard to talk about what you’re going through, especially if you’ve kept your anorexia a secret for a long time. You may be ashamed, ambivalent, or afraid. But it’s important to understand that you’re not alone. Find a good listener—someone who will support you as you try to get better.

Stay away from people, places, and activities that trigger your obsession with being thin. You may need to avoid looking at fashion or fitness magazines, spend less time with friends who constantly diet and talk about losing weight, and stay away from weight loss web sites and “pro-ana” sites that promote anorexia.

Seek professional help. The advice and support of trained eating disorder professionals can help you regain your health, learn to eat normally again, and develop healthier attitudes about food and your body.

Medical treatment for anorexia

The first priority in anorexia treatment is addressing and stabilizing any serious health issues. Hospitalization may be necessary if you are dangerously malnourished or so distressed that you no longer want to live. You may also need to be hospitalized until you reach a less critical weight.

Anorexia recovery tip 1: Understand this is not really about weight or food

The food and weight-related issues are in fact symptoms of something deeper: things like depression, anxiety, loneliness, insecurity, pressure to be perfect, or feeling out of control. Things that no amount of dieting or weight loss can cure.

The difference between dieting and anorexia
Healthy Dieting Anorexia

Healthy dieting is an attempt to control weight.

Anorexia is an attempt to control your life and emotions.

Your self-esteem is based on more than just weight and body image.

Your self-esteem is based entirely on how much you weigh and how thin you are.

You view weight loss as a way to improve your health and appearance.

You view weight loss as a way to achieve happiness.

Your goal is to lose weight in a healthy way.

Becoming thin is all that matters; health is not a concern.

In order to overcome anorexia, you first need to understand that it meets a need in your life. For example, maybe you feel powerless in many parts of your life, but you can control what you eat. Saying “no” to food, getting the best of hunger, and controlling the number on the scale may make you feel strong and successful—at least for a short while. You may even come to enjoy your hunger pangs as reminders of a “special talent” that most people don't possess.

Anorexia may also be a way of distracting yourself from difficult emotions. When you spend most of your time thinking about food, dieting, and weight loss, you don’t have to face other problems in your life or deal with complicated emotions. Restricting food may provide an emotional numbness, anesthetizing you from feelings of anxiety, sadness, or anger, perhaps even replacing those emotions with a sense of calm or safety.

Unfortunately, any boost you get from starving yourself or shedding pounds is extremely short-lived—and at some point, it will stop working for you at all. Dieting and weight loss can’t repair the negative self-image at the heart of anorexia. The only way to do that is to identify the emotional need that self-starvation fulfills and find other ways to meet it.

“I feel fat”

While your weight likely remains fairly constant over the course of, say, a week, feelings of fatness can fluctuate wildly. Often, feeling fat is a mislabeling of other emotions, such as shame, boredom, frustration, or sadness. In other words, “I feel fat” really means “I feel anxious,” or “I feel lonely.” And no diet is ever likely to change those feelings.

Tip 2: Learn to tolerate your feelings

Identifying the underlying issues that drive your eating disorder is the first step toward recovery, but insight alone is not enough. Let’s say, for example, that following restrictive food rules makes you feel safe and powerful. When you take that coping mechanism away, you will be confronted with the feelings of fear and helplessness your anorexia helped you avoid.

Reconnecting with your feelings can be extremely uncomfortable. It’s why you may feel worse at the beginning of your recovery. But the answer isn’t to return to the destructive eating habits you previously used to distract yourself; it’s to learn how to accept and tolerate all of your feelings—even the negative ones.

Using mindfulness to cope with difficult emotions

When you start to feel overwhelmed by negativity, discomfort, or the urge to restrict food, take a moment to stop whatever you’re doing and investigate what’s going on inside.

Identify the emotion you’re feeling. Is it guilt? Shame? Helplessness? Loneliness? Anxiety? Disappointment? Fear? Insecurity?

Accept the experience you’re having. Avoidance and resistance only make negative emotions stronger. Instead, try to accept what you’re feeling without judging yourself.

Dig deeper. Where do you feel the emotion in your body? What kinds of thoughts are going through your head?

Distance yourself. Realize that you are NOT your feelings. Emotions are passing events, like clouds moving across the sky. They don’t define who you are.

Once you learn how to accept and tolerate your feelings, they’ll no longer seem so scary. You’ll realize that you’re still in control and that negative emotions are only temporary. Once you stop fighting them, they’ll quickly pass.

For a step-by-step guide to learning how to manage stress and uncomfortable emotions, check out HelpGuide’s free Emotional Intelligence Toolkit.

New ways to find emotional fulfillment

Once you understand the link between your emotions and your disordered eating patterns—and can identify your triggers—you still need to find alternatives to dieting that you can turn to for emotional fulfillment. For example:

If you’re depressed or lonely, call someone who always makes you feel better, schedule time with family or friends, watch a comedy show, or play with a dog or cat.

If you’re anxious, expend your nervous energy by dancing to your favorite music, squeezing a stress ball, or taking a brisk walk or bike ride.

If you’re exhausted, treat yourself with a hot cup of tea, go for a walk, take a bath, or light some scented candles.

If you’re bored, read a good book, explore the outdoors, visit a museum, or turn to a hobby you enjoy (playing the guitar, knitting, shooting hoops, scrapbooking, etc.).

Tip 3: Challenge damaging mindsets

People with anorexia are often perfectionists and overachievers. They’re the “good” daughters and sons who do what they’re told, try to excel in everything they do, and focus on pleasing others. But while they may appear to have it all together, inside they feel helpless, inadequate, and worthless.

If that sounds familiar to you, here’s the good news: these feelings don’t reflect reality. They’re fueled by irrational, self-sabotaging ways of thinking that you can learn to overcome.

Damaging mindsets that fuel anorexia

All-or-nothing thinking. Through this harshly critical lens, if you’re not perfect, you’re a total failure. You have a hard time seeing shades of gray, at least when it comes to yourself.

Emotional reasoning. You believe if you feel a certain way, it must be true. “I feel fat” means “I am fat.” “I feel hopeless” means you’ll never get better.

Musts, must-nots, and have-tos. You hold yourself to a rigid set of rules (“I must not eat more than x number of calories, “I have to get straight A’s,”I must always be in control.” etc.) and beat yourself up if you break them.

Labeling. You call yourself names based on mistakes and perceived shortcomings. “I’m unhappy with how I look” becomes “I’m disgusting.” Slipping up becomes “I’m a “failure.”

Catastrophizing. You jump to the worst-case scenario. If you backslide in recovery, for example, you assume that there’s no hope you’ll ever get better.

Put your thoughts on the witness stand

Once you identify the destructive thoughts patterns that you default to, you can start to challenge them with questions such as:

  • “What’s the evidence that this thought is true? Not true?”
  • “What would I tell a friend who had this thought?”
  • “Is there another way of looking at the situation or an alternate explanation?”
  • “How might I look at this situation if I didn’t have anorexia?”

As you cross-examine your negative thoughts, you may be surprised at how quickly they crumble. In the process, you’ll develop a more balanced perspective.

Tip 4: Develop a healthier relationship with food

Even though anorexia isn’t fundamentally about food, over time you’ve developed harmful food habits that can be tough to break. Developing a healthier relationship with food entails:

  • Getting back to a healthy weight
  • Starting to eat more food
  • Changing how you think about yourself and food

Let go of rigid food rules. While following rigid rules may help you feel in control, it’s a temporary illusion. The truth is that these rules are controlling you, not the other way around. In order to get better, you’ll need to let go. This is a big change that will feel scary at first, but day by day, it will get easier.

Get back in touch with your body. If you have anorexia, you’ve learned to ignore your body’s hunger and fullness signals. You may not even recognize them anymore. The goal is to get back in touch with these internal cues, so you can eat based on your physiological needs.

Allow yourself to eat all foods. Instead of putting certain food off limits, eat whatever you want, but pay attention to how you feel physically after eating different foods. Ideally, what you eat should leave you feeling satisfied and energized.

Get rid of your scale. Instead of focusing on weight as a measurement of self-worth, focus on how you feel. Make health and vitality your goal, not a number on the scale.

Develop a healthy meal plan. If you need to gain weight, a nutritionist or dietician can help you develop a healthy meal plan that includes enough calories to get you back to a normal weight. While you can do this on your own, you’re probably out of touch with what a normal meal or serving size looks like.

Getting past your fear of gaining weight

Getting back to a normal weight is no easy task. The thought of gaining weight is probably extremely frightening, and you may be tempted to resist.

But this fear is a symptom of your anorexia. Reading about anorexia or talking to other people who have lived with it can help. It also helps to be honest about your feelings and fears. The better your family and treatment team understand what you’re going through, the better support you’ll receive.

Helping someone with anorexia

While there are things you can do to help someone with an eating disorder, you can’t force the person to get better. Having anorexia can distort the way your loved one thinks—about their body, the world around them, even your motivations for trying to help. Add to that the defensiveness and denial involved in anorexia and 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.

Think of yourself as an “outsider.” As someone not suffering from anorexia, there isn’t a lot you can do to “solve” your loved one’s anorexia. It is ultimately their choice to decide when they are ready.

Encourage your loved one to get help. The longer an eating disorder remains undiagnosed and untreated, the harder it is on the body and the more difficult it is to overcome, so urge your loved one to see a doctor as soon as possible.

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.

Be a role model for healthy eating, exercising, and body image. Don’t make negative comments about your own body or anyone else’s.

Don’t act like the food police. A person with anorexia needs compassion and support, not an authority figure standing over the table with a calorie counter.

Avoid threats, scare tactics, angry outbursts, and put-downs. Bear in mind that anorexia is often a symptom of extreme emotional distress and develops out of an attempt to manage emotional pain, stress, and/or self-hate. Negative communication will only make it worse.

Recommended reading

Almost Anorexic – Harvard Health Books

Treatment – National Eating Disorders Association

Helplines for eating disorders

U.S.: National Eating Disorders Association, 1-800-931-2237

UK: Beat Eating Disorders, 0345 643 1414

Australia: Butterfly Foundation for Eating Disorders, 1800 33 4673

Canada: National Eating Disorder Information Centre, 1-866-633-4220

Authors: Melinda Smith, M.A. and Jeanne Segal, Ph.D. Last updated: September 2018.

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