Anorexia nervosa

Anorexia (an-o-REK-see-uh) nervosa — often simply called anorexia — is an eating disorder characterized by an abnormally low body weight, intense fear of gaining weight and a distorted perception of body weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with activities in their lives.

To prevent weight gain or to continue losing weight, people with anorexia usually severely restrict the amount of food they eat. They may control calorie intake by vomiting after eating or by misusing laxatives, diet aids, diuretics or enemas. They may also try to lose weight by exercising excessively.

Some people with anorexia binge and purge, similar to individuals with bulimia nervosa. However, people with anorexia generally struggle with an abnormally low body weight, while individuals with bulimia typically are normal to above normal weight. No matter how weight loss is achieved, the person with anorexia has an intense fear of gaining weight.

Anorexia isn’t really about food. It’s an unhealthy way to try to cope with emotional problems. When you have anorexia, you often equate thinness with self-worth.

Anorexia can be very 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.

The physical signs and symptoms of anorexia nervosa are related to starvation, but the disorder also includes emotional and behavior issues related to an unrealistic perception of body weight and an extremely strong fear of gaining weight or becoming fat.

Physical symptoms

Physical signs and symptoms of anorexia may include:

• Extreme weight loss
• Thin appearance
• Abnormal blood counts
• Fatigue
• Insomnia
• Dizziness or fainting
• Bluish discoloration of the fingers
• Hair that thins, breaks or falls out
• Soft, downy hair covering the body
• Absence of menstruation
• Constipation
• Dry or yellowish skin
• Intolerance of cold
• Irregular heart rhythms
• Low blood pressure
• Dehydration
• Osteoporosis
• Swelling of arms or legs

Emotional and behavioral symptoms

Behavioral symptoms of anorexia may include attempts to lose weight by either:

• Severely restricting food intake through dieting or fasting and may include excessive exercise
• Bingeing and self-induced vomiting to get rid of the food and may include use of laxatives, enemas, diet aids or herbal products

Other emotional and behavioral signs and symptoms related to anorexia may include:

• Preoccupation with food
• Refusal to eat
• Denial of hunger
• Fear of gaining weight
• Lying about how much food has been eaten
• Flat mood (lack of emotion)
• Social withdrawal
• Irritability
• Reduced interest in sex
• Depressed mood
• Thoughts of suicide

When to see a doctor

Anorexia, like other eating disorders, can take over your life. Unfortunately, many people with anorexia don’t want treatment, at least initially. Their desire to remain thin overrides concerns about their health. If you have a loved one you’re worried about, urge her or him to talk to a doctor.

If you’re experiencing any of the problems listed above, or if you think you may have an eating disorder, get help. If you’re hiding your anorexia from loved ones, try to find a confidant you can talk to about what’s going on.

Red flags to watch for

It may be hard to notice signs and symptoms of anorexia because people with anorexia often 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 spitting food out after chewing
• Cooking elaborate meals for others but refusing to eat
• Repeated weighing or measuring of themselves
• Frequent checking in the mirror for perceived flaws
• Complaining about being fat
• Not wanting to eat in public
• Calluses on the knuckles and eroded teeth if inducing vomiting
• Covering up in layers of clothing

The exact cause of anorexia nervosa is unknown. As with many diseases, it’s probably a combination of biological, psychological and environmental factors.

• Biological. Although it’s not yet clear which genes are involved, there may be genetic changes that make some people more vulnerable to developing anorexia. Some people may have a genetic tendency toward perfectionism, sensitivity and perseverance — all traits associated with anorexia.
• Psychological. Some emotional characteristics may contribute to anorexia. Young women 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 causes them to think they’re never thin enough. And they may have high levels of anxiety and engage in restrictive eating to reduce it.
• Environmental. Modern Western culture emphasizes thinness. Success and worth are often equated with being thin. Peer pressure may help fuel the desire to be thin, particularly among young girls.

Certain risk factors increase the risk of anorexia nervosa, 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.
• Young age. Anorexia is more common among teenagers. Still, people of any age can develop this eating disorder, though it’s rare in those over 40. Teens may be more susceptible because of all the changes their bodies go through during puberty. They also may face increased peer pressure and be more sensitive to criticism or even casual comments about weight or body shape.
• Genetics. Changes in certain genes may make people more susceptible to anorexia.
• Family history. Those with a first-degree relative — a parent, sibling or child — who had the disease have a much higher risk of anorexia.
• 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. In addition, starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.
• 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 stress and increase the risk of anorexia.
• Sports, work and artistic activities. Athletes, actors, dancers and models are at higher risk of anorexia. Coaches and parents may inadvertently raise the risk by suggesting that young athletes lose weight.
• Media and society. The media, such as TV and fashion magazines, frequently feature a parade of skinny models and actors. These images may seem to equate thinness with success and popularity. But whether the media merely reflect social values or actually drive them isn’t clear-cut.

Anorexia nervosa 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.

Other complications of anorexia include:

• Anemia
• Heart problems, such as mitral valve prolapse, abnormal heart rhythms or 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
• Suicide

If a person with anorexia becomes severely malnourished, every organ in the body can be damaged, 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:

• Depression, anxiety and other mood disorders
• Personality disorders
• Obsessive-compulsive disorders
• Alcohol and substance misuse

Here’s some information to help you get ready for your appointment and know what to expect from your doctor and other health providers.

What you can do

Before your appointment, make a list of:

• Any symptoms you’re experiencing, including any that may seem unrelated to the reason for the appointment. Try to recall when your symptoms began.
• Key personal information, including any major stresses or recent life changes.
• All medications, vitamins and other supplements that you’re taking and their doses.
• Questions to ask your doctor so that you’ll remember to cover everything you wanted to.

Ask a family member or friend to go with you, if possible. Someone who accompanies you may remember something that you missed or forgot. A family member may also be able to give your doctor a fuller picture of your home life.

Some questions you might want to ask your doctor or other health care provider include:

• What kinds of tests do I need? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• Is there a generic alternative to the medicine you’re prescribing for me?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don’t hesitate to ask questions anytime you don’t understand something.

What to expect from your doctor

Your doctor or other health care provider is likely to ask you a number of questions, such as:

• How long have you been worried about your weight?
• Do you exercise? How often?
• Have you found any other ways to lose weight?
• Are you having any physical symptoms?
• Have you ever vomited because you were uncomfortably full?
• Have others expressed concern that you’re too thin?
• Do you think about food often?
• Do you ever eat in secret?
• Have any of your family members ever had symptoms of an eating disorder or been diagnosed with an eating disorder?

If your doctor suspects that you have anorexia nervosa, he or she will typically run several tests and exams to help pinpoint a diagnosis, rule out medical causes for the weight loss, and 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 problems; listening to your heart and lungs; and examining your abdomen.
• Lab tests. These may include a complete blood count (CBC) and 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 will likely ask about your thoughts, feelings and eating habits. You may also be asked to complete psychological self-assessment questionnaires.
• Other studies. X-rays may be taken to check your bone density, check for stress fractures or broken bones, or check for pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities. 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 nervosa, you generally must meet criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

DSM-5 diagnostic criteria for anorexia include:

• Restricting food intake — eating less than needed to maintain a body weight that’s at or above the minimum normal weight for your age and height
• Fear of gaining weight — intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, such as vomiting or using laxatives, even though you’re underweight
• Problems with body image — denying the seriousness of having a low body weight, connecting your weight to your self-worth, or having a distorted image of your appearance or shape

When you have anorexia nervosa, you may need several types of treatment. Treatment is generally done using a team approach that includes medical providers, mental health providers and dietitians, all with experience in eating disorders. Ongoing therapy and nutrition education are highly important to continued recovery.

Here’s a look at what’s commonly involved in treating people with anorexia.

Hospitalization and other programs

If your life is in immediate danger, you may need treatment in a hospital emergency room for such issues as a heart rhythm disturbance, dehydration, electrolyte imbalances or psychiatric problems. Hospitalization may be required for medical complications, psychiatric emergencies, severe malnutrition or continued refusal to eat. 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.

Medical care

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 can’t recover from an eating disorder without restoring an appropriate weight and learning proper nutrition.

A psychologist or other mental health professional can work with you to develop behavioral strategies to help you return to a healthy weight. A dietitian can offer guidance getting back to regular patterns of eating, including providing specific meal plans and calorie requirements that help you meet your weight goals. Your family will also likely be involved in helping you maintain normal eating habits.

Psychotherapy

These types of therapy may be beneficial:

• Family-based therapy. This is the only evidence-based treatment for teenagers with anorexia. Because the teenager with anorexia is unable to make good choices about eating and health while in the grips of this serious condition, this therapy mobilizes parents to help their child with re-feeding and weight restoration until the child can make good choices about health.
• Individual therapy. For adults, cognitive behavioral therapy — specifically enhanced cognitive behavioral therapy — has been shown to help. The main goal is to normalize eating patterns and behaviors to support weight gain. The second goal is to help change distorted beliefs and thoughts that maintain the restrictive eating. This type of therapy is generally done once a week or in a day treatment program, but in some cases, it may be part of treatment in a psychiatric hospital.

Medications

No medications are approved to treat anorexia because none has been found to work very well. However, antidepressants or other psychiatric medications can help treat other mental disorders you may also have, such as depression or anxiety.

Treatment challenges in anorexia

One of the biggest challenges in treating anorexia is that people may not want treatment. Barriers to treatment may include:

• Thinking you don’t need treatment
• Fearing weight gain
• Not seeing anorexia as an illness but rather a lifestyle choice

People with eating disorders can recover. However, they’re at increased risk of relapse during periods of high stress or during triggering situations. Ongoing therapy or periodic appointments during times of stress may help you stay healthy.

When you have anorexia nervosa, 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.

Alternative medicine is the use of a nonconventional approach instead of conventional medicine. Complementary medicine is a nonconventional approach used along with conventional medicine.

Alternative medicine hasn’t been well-studied as a treatment for people with eating disorders, but complementary treatments may help reduce anxiety. Such treatments may help people with eating disorders by increasing a sense of well-being and promoting relaxation.

Examples of anxiety-reducing complementary treatments include:

• Acupuncture
• Massage
• Yoga
• Meditation

Talk with your doctor before trying any alternative medicine. Natural doesn’t always mean safe. Your doctor can help you understand possible risks and benefits before you try a treatment.

You may find it difficult to cope with anorexia nervosa 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.

Whether you have anorexia or your loved one has anorexia, ask your doctor or therapist for advice on coping strategies and emotional support. Learning effective coping strategies and getting the support you need from family and friends are vital to successful treatment.

There’s no guaranteed way to prevent anorexia nervosa. Primary care physicians (pediatricians, family physicians and internists) may be in a good position to identify early indicators of anorexia and prevent the development of full-blown illness. For instance, they can ask questions about eating habits and satisfaction with appearance during routine medical appointments.

If you notice that a family member or friend has low self-esteem, severe dieting habits 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.

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