What is it?
- Anorexia nervosa is an eating disorder that causes people to obsess about their weight and the food they eat. People with anorexia nervosa attempt to maintain a weight that's far below normal for their age and height. To prevent weight gain or to continue losing weight, people with anorexia nervosa may starve themselves or exercise excessively.
- Anorexia (an-oh-REK-see-uh) nervosa isn't really about food. It's an unhealthy way to try to cope with emotional problems. When you have anorexia nervosa, you often equate thinness with self-worth.
- Anorexia nervosa can be difficult to overcome. But with treatment, you can gain a better sense of who you are, return to healthier eating habits and reverse some of anorexia's serious complications.
- Some people with anorexia lose weight mainly through severely restricting the amount of food they eat. They may also try to lose weight by exercising excessively. Others with anorexia engage in binging and purging, similar to bulimia. They control calorie intake by vomiting after eating or by misusing laxatives, diuretics or enemas.
- No matter how weight loss is achieved, anorexia has a number of physical, emotional and behavioral signs and symptoms.
Physical anorexia symptoms
Physical signs and symptoms of anorexia include:
- Extreme weight loss
- Thin appearance
- Abnormal blood counts
- Dizziness or fainting
- A bluish discoloration of the fingers
- Brittle nails
- Hair that thins, breaks or falls out
- Soft, downy hair covering the body
- Absence of menstruation
- Dry skin
- Intolerance of cold
- Irregular heart rhythms
- Low blood pressure
- Swelling of arms or legs
Emotional and behavioral anorexia symptoms
Emotional and behavioral characteristics associated with anorexia include:
- Refusal to eat
- Denial of hunger
- Excessive exercise
- Flat mood, or lack of emotion
- Social withdrawal
- Preoccupation with food
- Reduced interest in sex
- Depressed mood
- Possible use of herbal products or diet aids
Anorexia red flags to watch for
It may be hard to notice signs and symptoms of anorexia because people with anorexia often go to great lengths to disguise their thinness, eating habits or physical problems.
If you're concerned that a loved one may have anorexia, watch for these possible red flags:
- Skipping meals
- Making excuses for not eating
- Eating only a few certain "safe" foods, usually those low in fat and calories
- Adopting rigid meal or eating rituals, such as cutting food into tiny pieces or spitting food out after chewing
- Cooking elaborate meals for others but refusing to eat
- Repeated weighing of themselves
- Frequent checking in the mirror for perceived flaws
- Complaining about being fat
- Not wanting to eat in public
It's not known specifically what causes some people to develop anorexia. As with many diseases, it's likely a combination of biological, psychological and sociocultural factors.
- Biological. Some people may be genetically vulnerable to developing anorexia. Young women with a biological sister or mother with an eating disorder are at higher risk, for example, suggesting a possible genetic link. Studies of twins also support that idea. However, it's not clear specifically how genetics may play a role, although researchers have discovered an area on chromosome 1 that appears to be associated with an increased susceptibility to anorexia nervosa.
- It may also be that some people have a genetic tendency toward perfectionism, sensitivity and perseverance, all traits associated with anorexia. There's also some evidence that serotonin — one of the brain chemicals involved in depression — may play a role in anorexia.
- Psychological. People with anorexia may have psychological and emotional characteristics that contribute to anorexia. They may have low self-worth, for instance. They may have obsessive-compulsive personality traits that make it easier to stick to strict diets and forgo food despite being hungry. They may have an extreme drive for perfectionism, which means they may never think they're thin enough.
- Sociocultural. Modern Western culture often cultivates and reinforces a desire for thinness. The media are splashed with images of thin models and actors. Success and worth are often equated with being thin. Peer pressure may fuel the desire to be thin, particularly among young girls. However, anorexia and other eating disorders existed centuries ago, suggesting that sociocultural values aren't solely responsible.
Certain risk factors increase the risk of anorexia, including:
- Being female. Anorexia is more common in girls and women. However, boys and men have been increasingly developing eating disorders, perhaps because of growing social pressures.
- A young age. Anorexia is more common among teenagers. Still, people of any age can develop this eating disorder, though it's rare in people older than 40. Teenagers may be more susceptible because of all of the changes their bodies go through during puberty. They also may face increased peer pressure and may be more sensitive to criticism or even casual comments about weight or body shape.
- Genetics. Researchers have found an area on chromosome 1 that appears to be linked to an increased risk of anorexia nervosa. Additionally, anorexia nervosa runs in families, another factor that suggests a genetic component. Women with a first-degree relative — a parent, sibling or child — who had the disease have a dramatically increased risk of developing anorexia nervosa.
- Weight changes. When people lose or gain weight — on purpose or unintentionally — those changes may be reinforced by positive comments from others if weight was lost, or by negative comments if there was a weight gain. Such changes and comments may trigger someone to start dieting to an extreme.
- Transitions. Whether it's a new school, home or job, a relationship breakup, or the death or illness of a loved one, change can bring emotional distress and increase the risk of anorexia nervosa.
- Sports, work and artistic activities. Athletes, actors and television personalities, dancers, and models are at higher risk of anorexia. For some, such as ballerinas, ultrathinness may even be a professional requirement. Sports associated with anorexia include running, wrestling, figure skating and gymnastics. Professional men and women may believe they'll improve their upward mobility by losing weight, and then take it to an extreme. Coaches and parents may inadvertently raise the risk by suggesting that young athletes lose weight.
- Media and society. The media, such as television and fashion magazines, frequently feature a parade of skinny models and actors. But whether the media merely reflect social values or actually drive them isn't clear-cut. In any case, these images may seem to equate thinness with success and popularity.
Anorexia can have numerous complications. At its most severe, it can be fatal. Death may occur suddenly — even when someone is not severely underweight. This may result from abnormal heart rhythms (arrhythmias) or an imbalance of electrolytes — minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body.
Complications of anorexia include:
- Heart problems, such as mitral valve prolapse, abnormal heart rhythms and heart failure
- Bone loss, increasing risk of fractures later in life
- In females, absence of a period
- In males, decreased testosterone
- Gastrointestinal problems, such as constipation, bloating or nausea
- Electrolyte abnormalities, such as low blood potassium, sodium and chloride
- Kidney problems
If a person with anorexia becomes severely malnourished, every organ in the body can sustain damage, including the brain, heart and kidneys. This damage may not be fully reversible, even when the anorexia is under control.
In addition to the host of physical complications, people with anorexia also commonly have other mental disorders as well. They may include:
When doctors suspect someone has anorexia, they typically run a battery of tests and exams to help pinpoint a diagnosis, rule out medical causes for the weight loss and also check for any related complications.
These exams and tests generally include:
- Physical exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; checking your skin and nails for dryness or other problems; listening to your heart and lungs; and examining your abdomen.
- Laboratory tests. These may include a complete blood count (CBC), as well as more specialized blood tests to check electrolytes and protein as well as functioning of your liver, kidney and thyroid. A urinalysis also may be done.
- Psychological evaluation. A doctor or mental health provider can assess thoughts, feelings and eating habits. Psychological self-assessments and questionnaires also are used.
- Other studies. X-rays may be taken to check for broken bones, pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities. Bone density testing may be done to check your bone health. Testing may also be done to determine how much energy your body uses, which can help in planning nutritional requirements.
Diagnostic criteria for anorexia
To be diagnosed with anorexia, you generally must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DMS), published by the American Psychiatric Association.
DSM diagnostic criteria for anorexia are:
- Refusal to maintain a body weight that is at or above the minimum normal weight for your age and height
- Intense fear of gaining weight or becoming fat, even though you're underweight
- Denying the seriousness of having a low body weight, or having a distorted image of your appearance or shape
- In women who've started having periods, the absence of a period for at least three consecutive menstrual cycles
Treatments and drugs
When you have anorexia, you may need several types of treatment. If your life is in immediate danger, you may need treatment in a hospital emergency department for such issues as a heart rhythm disturbance, dehydration, electrolyte imbalances or psychiatric problems.
Here's a look at what's commonly involved in treating people with anorexia:
Because of the host of complications anorexia causes, you may need frequent monitoring of vital signs, hydration level and electrolytes, as well as related physical conditions. In severe cases, people with anorexia may initially require feeding through a tube that's placed in their nose and goes to the stomach (nasogastric tube). A primary care doctor may be the one who coordinates care with the other health care professionals involved. Sometimes, though, it's the mental health provider who coordinates care.
Restoring a healthy weight
The first goal of treatment is getting back to a healthy weight. You cannot recover from an eating disorder without restoring an appropriate weight and learning proper nutrition. A dietitian can offer guidance on a healthy diet, including providing specific meal plans and calorie requirements that will help you meet your weight goals. Your family will also likely be involved in helping you maintain healthy-eating habits.
Individual, family-based and group therapy may all be beneficial.
- Individual therapy. This type of therapy can help you deal with the behavior and thoughts that contribute to anorexia. You can gain a healthier self-esteem and learn positive ways to cope with distress and other strong feelings. A type of talk therapy called cognitive behavioral therapy (CBT) is commonly used but lacks strong evidence that it's superior to other forms of therapy for treating anorexia nervosa. A mental health provider can help assess the need for psychiatric hospitalization or day treatment programs.
- Family-based therapy. This therapy begins with the assumption that the person with the eating disorder is no longer capable of making sound decisions regarding his or her health and needs help from the family. An important part of family-based therapy is that the family is involved in making sure that healthy-eating patterns are followed. This type of therapy can help resolve family conflicts and muster support from concerned family members. Family-based therapy can be especially important for children with anorexia who still live at home.
- Group therapy. This type of therapy gives you a way to connect to others facing eating disorders. And informal support groups may sometimes be helpful. However, be careful with informal groups that aren't led by a mental health professional. For some people with anorexia, support groups might result in competitions to be the thinnest person there.
There are no medications specifically designed to treat anorexia because they've shown limited benefit in treating this eating disorder. However, antidepressants or other psychiatric medications can help treat other mental disorders you may also have, such as depression or anxiety.
In cases of medical complications, psychiatric emergencies, severe malnutrition or continued refusal to eat, hospitalization may be needed. Hospitalization may be on a medical or psychiatric ward. Some clinics specialize in treating people with eating disorders. Some may offer day programs or residential programs, rather than full hospitalization. Specialized eating disorder programs may offer more intensive treatment over longer periods of time. Also, even after hospitalization ends, ongoing therapy and nutrition education are highly important to continued recovery.
Treatment challenges in anorexia
Some cases of anorexia are much more severe than others. Less severe cases may take less time for treatment and recovery. One of the biggest challenges in treating anorexia is that people may not want treatment, may think they don't need it or may be concerned about weight gain. And, some people with anorexia promote it as a lifestyle choice. They don't consider it an illness. Pro-anorexia (pro-ana) Web sites can be found on the Internet, and some even offer tips on which foods to avoid and how to fight hunger pangs.
Even if you do want to get better, the pull of anorexia can be difficult to overcome. Anorexia is often an ongoing, lifelong battle. Although symptoms may subside, you remain vulnerable and may have a relapse during periods of high stress or during triggering situations. For example, anorexia symptoms may subside during pregnancy only to return once your baby has been delivered. Ongoing therapy or periodic appointments during times of stress may be helpful.
When you have anorexia, it can be difficult to take care of yourself properly. In addition to professional treatment, follow these steps:
- Stick to your treatment plan. Don't skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
- Talk to your doctor about appropriate vitamin and mineral supplements. If you're not eating well, chances are your body isn't getting all of the nutrients it needs.
- Don't isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart.
- Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.
Although yoga has not yet been well studied as a treatment for people with eating disorders, some research has found that yoga may be beneficial as an additional treatment. It may help people with eating disorders by increasing a sense of well-being and promoting relaxation.
Coping and support
You may find it difficult to cope with anorexia when you're hit with mixed messages by the media, culture, and perhaps your own family or friends. You may even have heard people joke that they wish they could have anorexia for a while so that they could lose weight.
So how do you cope with a disease that can be deadly when you may be getting messages that being thin is a sign of success?
- Remind yourself what a healthy weight is for your body, especially at times when you see images that may trigger your desire to restrict calories.
- Don't visit pro-anorexia Web sites. These sites can encourage you to maintain dangerous habits and trigger relapses. Anorexia isn't a lifestyle choice. It's a disease.
- Acknowledge that you may not always be the best judge of whether you're eating enough or are at a healthy weight.
- Identify problem situations that are likely to trigger thoughts or behavior that may contribute to your anorexia so that you can develop a plan of action to deal with them.
- Look for positive role models. Remind yourself that ultrathin models or actors showcased in women's magazines or gossip magazines may not represent healthy bodies.
There's no guaranteed way to prevent anorexia or other eating disorders. Primary care physicians (pediatricians, family physicians and internists) may be in a good position to identify early indicators of an eating disorder and prevent the development of full-blown illness. They can ask questions about eating habits and satisfaction with appearance during routine medical appointments, for instance.
If you notice a family member or friend with low self-esteem, severe dieting and dissatisfaction with appearance, consider talking to him or her about these issues. Although you may not be able to prevent an eating disorder from developing, you can talk about healthier behavior or treatment options.