Anorexia nervosa is an eating disorder that involves self-imposed starvation. The individual is obsessed with becoming increasingly thinner and limits food intake to the point where health is compromised. Anorexia nervosa can be fatal.
Competitive athletes have an increased risk of developing anorexia nervosa, especially in sports where weight is tied to performance. Jockeys, wrestlers, figure skaters, cross-country runners, and gymnasts (especially female gymnasts) have higher than average rates of anorexia. People such as actors, models, cheerleaders, and dancers (especially ballet dancers) who are judged mainly on their appearance are also at high risk of developing the disorder.
Anorexia is often thought of as a modern problem, but the English physician Richard Morton first described it in 1689. In the twenty-first century, anorexia nervosa is recognized as a psychiatric disorder in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association.
Anorexia often starts with a decision to follow a strict weight-loss diet. A person who severely limits food frequently becomes malnourished and experiences unhealthy weight loss. Malnutrition then causes changes in both the brain and metabolism that limit appetite, changes how the body uses food, and interferes with the ability to think clearly and make good decisions. As anorexia progresses, irrational behaviors begin, such as setting strict rules about food or making oneself vomit to avoid gaining weight.
Individuals with anorexia are on an irrational, unrelenting quest to lose weight, and no matter how much they lose and how much their health is compromised, they want to lose more weight. Recognizing the development of anorexia can be difficult, but dieting is often a trigger. Warning signs for anorexia may include skipping meals, taking only tiny portions, being secretive about food, not wanting to eat in public, or having sudden concerns about body image. The person may seem to always have an excuse for not eating, such as not feeling hungry, feeling ill, having just eaten with someone else, or not liking the food served. The person may also begin to read food labels obsessively and know exactly how many calories and how much fat are in foods. Many people with anorexia practically eliminate fat and sugar from their diets. Some people may exercise compulsively to burn extra calories. These practices can have serious health consequences. At some point, the line between problem eating and an eating disorder is crossed.
People with anorexia may spend a lot of time looking in the mirror, obsessing about clothing size and practicing negative self-talk about their bodies. Some are secretive about eating and will avoid eating in front of other people. They may develop strange eating habits such as chewing their food and then spitting it out, or they may have rigid ideas about “good” and “bad” food. People with anorexia may hide their eating habits and their weight from friends, family, and healthcare providers. Many experience depression and anxiety disorders.
Certain personality types appear to be more vulnerable to developing anorexia nervosa. People with anorexia tend to be perfectionists who have unrealistic expectations about how they “should” look and perform. They tend to have a black-and-white, right-or-wrong, all-or-nothing way of seeing situations. Many people with anorexia lack a strong sense of identity and instead take their identity from pleasing others.
Most have low self-worth. Many experience depression and anxiety disorders, although researchers do not know if this is a cause or a result of the eating disorder.
Anorexic behaviors include:
Physical symptoms of anorexia include:
Diagnosis is based on several factors including a patient history, physical examination, laboratory tests, and a mental status evaluation. A patient history is less helpful in diagnosing anorexia than in diagnosing many diseases because many people with anorexia lie repeatedly about how much they eat and their use of laxatives, enemas, and medications. The patient may, however, complain about related symptoms such as fatigue, headaches, dizziness, constipation, or frequent infections.
A physical examination begins with weight and blood pressure and then checks for potential malnutrition symptoms. Based on the physical exam, the physician may order laboratory tests. In general, these tests will include a complete blood count (CBC), urinalysis, metabolic panel, blood chemistries (to determine electrolyte levels), and liver function tests. The physician may also order an electrocardiogram to look for heart abnormalities and x-rays to see if bones are weakened.
Several different mental status evaluations can be used. In general, the physician will evaluate things such as orientation in time and space, appearance, observable state of emotion (affect), attitude toward food and weight, delusional thinking, and thoughts of self-harm or suicide.
Everyone with anorexia needs treatment, which usually involves doctor visits and regular counseling sessions. Treatment choices depend on the degree to which anorexic behavior has resulted in physical damage and whether the patients are a danger to themselves. Medical treatment must be supplemented with psychiatric treatment. Patients are frequently uncooperative and resist treatment, denying that their life may be endangered and insisting that the doctor only wants to “make them get fat.” For teenagers, family involvement in treatment is essential. Family therapy helps parents learn to support their child emotionally and physically. Family therapy also helps the child's siblings to cope.
Hospital impatient care is first geared toward correcting problems that present immediate medical crises such as severe malnutrition, severe electrolyte imbalance, irregular heartbeat, pulse below 45 beats per minute, or low body temperature. Patients are hospitalized if they are a high suicide risk, have severe clinical depression, or exhibit signs of an altered mental state. They may also need to be hospitalized to interrupt weight loss; stop the cycle of vomiting, exercising, and/or laxative abuse; treat substance disorders; or for additional medical evaluation.
Day treatment or partial hospitalization, where the patient goes every day to an extensive treatment program, provides structured mealtimes, nutrition education, intensive therapy, medical monitoring, and supervision. If day treatment fails, the patient may need to be hospitalized or enter a full-time residential treatment facility.
A nutrition consultant or dietitian is an essential part of the team needed to successfully treat anorexia. The first treatment concern is to get the individual medically stable by increasing calorie intake and balancing electrolytes. After that, nutritional therapy is needed to support the long process of recovery and stable weight gain. This is an intensive process involving nutrition education, meal planning, nutrition monitoring, and helping the patient develop a healthy relationship with food.
Medical intervention helps alleviate the immediate physical problems associated with anorexia, but by itself, it rarely changes behavior. Psychotherapy plays a major role in helping an individual understand and recover from anorexia. Several different types of psychotherapy are used depending on the situation. Generally, the goal of psychotherapy is to help individuals develop a healthy attitude toward their body and food. This may involve addressing the root causes of anorexic behavior as well as addressing the behavior itself.
Some types of psychotherapy that have been successful in treating anorexia include:
Anorexia nervosa is difficult to treat successfully. Medical stabilization, nutrition therapy, continued medical monitoring, and substantial psychiatric treatment give a person with anorexia the best chance of recovery. It is common for people to drop out of treatment too soon. Relapses are also expected. Treating is often a long, slow, frustrating process that can cost thousands of dollars. The earlier in life that the disorder starts and the longer the disorder continues untreated, the more difficult it is bringing about recovery. Many individuals with anorexia are willfully uncooperative and do not want to recover.
Research has found that a mother's attitude toward body weight and dieting may have a significant impact on her children's views. Some behaviors to try prevent anorexia nervosa from developing include:
Relapses happen to many people with anorexia. People who are recovering from anorexia can help prevent relapse by:
See also Adolescent nutrition ; Binge eating ; Body image ; Body mass index ; Bulimia nervosa ; Calorie restriction ; Eating disorders ; Malnutrition ; Nutrition and mental health ; Weight cycling .
Anderson, Leslie, Stuart Murray, and Walter H. Kaye. Clinical Handbook of Complex and Atypical Eating Disorders. New York: Oxford University Press, 2018.
Grabowski, Amy Yandel. An Internal Family Systems Guide to Recovery from Eating Disorders: Healing Part by Part. New York: Routledge, 2018.
Heaton, Jeanne Albronda, and Claudia J. Strauss. Talking to Eating Disorders: Simple Ways to Support Someone Who Has Anorexia, Bulimia, Binge Eating, or Body Image Issues. New York: New American Library, 2014.
Herzog, David B., Debra L. Franko, and Pat Cable. Unlocking the Mysteries of Eating Disorders. New York: McGraw-Hill, 2008.
Landau, Jennifer. Teens Talk about Body Image and Eating Disorders. New York: Rosen, 2018.
Arcelus, Jon, Alex J. Mitchell, Jackie Wales, et al. “Mortality Rates in Patients with Anorexia Nervosa and Other Eating Disorders: A Meta-Analysis of 36 Studies.” Archives of General Psychiatry 68, no. 7 (July 2011): 724–31.
Borzekowski, Dina L. G., S. Schenk, J. R. Wilson, et al. “E-Ana and e-Mia: A Content Analysis of Pro-Eating Disorder Web Sites.” American Journal of Public Health 100, no. 8 (August 2010): 1526–34.
Genders, R., and K. Tchanturia. “Cognitive Remediation Therapy (CRT) for Anorexia in Group Format: A Pilot Study.” Eating and Weight Disorders 15, no. 4 (December 2010): e234–39.
Hudson, James, Eva Hiripi, Harrison Graham Pope Jr., et al. “The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication.” Biological Psychiatry 61, no. 3 (February 2007): 348–58.
Peebles, Rebecka, J. L. Wilson, I. F. Litt, et al. “Disordered Eating in a Digital Age: Eating Behaviors, Health, and Quality of Life in Users of Websites with Pro-Eating Disorder Content.” Journal of Medical Internet Research 14, no. 5 (October 25, 2012): e148.
Sabel, Allison L., Elissa Rosen, and Philip S. Mehler. “Severe Anorexia Nervosa in Males: Clinical Presentations and Medical Treatment.” Journal of Treatment and Prevention 22, no. 3 (March 2014): 209–20.
Singhal V., M. Misra, and A. Klibanski. “Endocrinology of Anorexia Nervosa in Young People: Recent Insights.” Current Opinion in Endocrinology, Diabetes, and Obesity 21, no. 1 (February 2014): 64–70.
Zipfel, Stephan, Katrin Giel, Cynthia M. Bulik, et al. “Anorexia Nervosa: Aetiology, Assessment, and Treatment.” Lancet Psychiatry 2, no. 12 (October 2015): 1099–111.
Bernstein, Bettina E. “Anorexia Nervosa.” Medscape. April 21, 2017. http://emedicine.medscape.com/article/912187-overview (accessed April 4, 2018).
Brownell, Kelly D., Kathy J. Hotelling, Michael R. Lowe, et al. “Eating Disorders.” American Psychological Association. http://www.apa.org/helpcenter/eating.aspx (accessed April 4, 2018).
MedlinePlus. “Eating Disorders.” U.S. National Library of Medicine, National Institutes of Health. http://www.nlm.nih.gov/medlineplus/eatingdisorders.html (accessed April 4, 2018).
American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave. NW, Washington, DC, 20016-3007, (202) 966-7300, Fax: (202) 464-0131, http://aacap.org .
American Psychiatric Association, 800 Maine Ave., SW, Ste. 900, Washington, DC, 20024, (202) 559-3900, http://www.psychiatry.org .
American Psychological Association, 750 First St., NE, Washington, DC, 20002-4242, (202) 336-5500, TTY: (202) 336-6123, (800) 374-2721, http://www.apa.org .
National Association of Anorexia Nervosa and Associated Disorders, PO Box 640, Naperville, IL, 60566, (630) 577-1330, email@example.com, http://www.anad.org .
Tish Davidson, AM
Revised by Jeanie Simoncic