Anorexia Nervosa
Anorexia nervosa is a serious eating disorder and mental health condition that affects nearly 30 million Americans during their lifetimes, carrying one of the highest death rates of any psychiatric illness—yet with proper treatment, recovery and healing are possible.
Table of contents
- What is anorexia nervosa?
- Types of anorexia nervosa
- Signs and symptoms
- What causes anorexia nervosa?
- Health risks and complications
- How is anorexia nervosa diagnosed?
- Treatment approaches
- Getting help
What is anorexia nervosa?
Anorexia nervosa is a treatable eating disorder (a serious mental health condition) in which a person severely limits their calorie intake to an extreme[2][4]. In medical language, “anorexia” means not wanting to eat. Adding “nervosa” to anorexia indicates it’s a mental health condition, meaning it’s based in the nervous system—in the brain, nerves, impulses, and thoughts[4].
People with anorexia nervosa have a low body weight based on their personal weight history. Although many people with anorexia look very thin, some may not look thin and others may look overweight—but they’ve actually lost weight or failed to gain needed weight[2]. The condition leads to malnutrition, which is when people don’t get the nutrients their bodies need to stay healthy[2].
People who have anorexia often have a strong fear of gaining weight and may think they’re overweight even when they’re thin[2]. They place a high value on controlling their weight and shape and use extreme efforts that can greatly harm their lives[2].
This condition develops from negative thoughts and feelings about eating, weight, and body image. Thoughts and worries about these things, and attempts to control them, are common in many people. But with anorexia nervosa, they become overwhelming and can have serious consequences for both mental and physical health[4].
Types of anorexia nervosa
There are two main types of anorexia nervosa, based on the eating behaviors involved[4][7]:
Restrictive anorexia involves severe calorie restriction alone. People with this type restrict the amount and type of food they eat. This can include counting calories, skipping meals, limiting or avoiding certain food groups (such as carbohydrates), and following obsessive rules, such as only eating foods of a certain color[4][7]. These behaviors may be accompanied by excessive exercise.
Binge-purge anorexia involves calorie restriction, but also episodes of binge eating and purging, similar to bulimia nervosa. Purging might mean vomiting, using laxatives or diuretics (water pills), or extensive exercising[4][7]. Some people may binge eat—eating a large amount of food and feeling out of control.
Atypical anorexia nervosa is anorexia in someone who isn’t yet underweight, making it harder to recognize[4][7]. This is when you have all the behaviors of anorexia nervosa, but your body mass index (BMI) is normal or above.
Signs and symptoms
Anorexia nervosa causes a wide range of physical, behavioral, and mental signs and symptoms, which can affect each person differently. Not everyone with anorexia nervosa has all the signs and symptoms[15].
Physical signs and symptoms
The most obvious physical signs of anorexia nervosa include being underweight, losing weight very quickly, or having dramatic weight fluctuations[7]. In children under 18, weight and height may be lower than the minimum expected for their age[5].
Other physical symptoms may include[4][5][7]:
- Abnormal heart rhythms
- Dizziness, lightheadedness, or fainting
- Fatigue and physical weakness
- Feeling cold all the time and low body temperature
- Hair loss or fine hair growing on the face and body
- Irregular periods or absent periods in women who have not reached menopause, or periods not starting in younger women and girls
- Swelling in the arms, legs, hands, or feet
- Dry skin and dehydration
- Yellow or blotchy skin
- Looking pale or having sunken eyes
- Bloating, constipation, or developing food intolerances
- Tooth decay from induced vomiting
Behavioral signs
Behaviors that are common in anorexia nervosa include[4][5][7][15]:
- Missing meals or eating very little
- Eating only a few types of foods or only low-calorie foods
- Avoiding eating any foods seen as fattening
- Being very careful about what you eat and thinking about food a lot
- Intense focus on food types and quantities and counting calories
- Exercising excessively, even when tired, sick, or injured
- Making themselves sick (vomit) or taking laxatives, diuretics, or diet aids
- Frequently skipping meals
- Cooking for others but not eating
- Not attending events that include food (birthdays, holidays)
- Frequently weighing themselves
- Consistently going to the bathroom right after eating
Emotional and mental signs
Emotional signs and symptoms include[7][15]:
- Believing you’re fat when you’re a healthy weight or underweight
- Frequent critical thoughts and comments about body weight and image
- Thinking about food, eating, body size, or shape constantly
- Distorted body image—seeing themselves as overweight even when they’re dangerously underweight
- Listlessness, depression, or flat mood
- Social withdrawal
- Feeling irritable
- Difficulty sleeping
- Reduced interest in sex
- Difficulty concentrating on activities (work, school)
- Reduced interest and enjoyment from previous activities
What causes anorexia nervosa?
There’s no single cause of anorexia nervosa. The exact cause is unknown, but researchers believe that eating disorders are caused by a complex interaction of factors[6]. Several factors may be involved, including biological, genetic, psychological, and social factors[4][5].
Biological and brain differences
Studies demonstrate biological factors play a role in the development of anorexia nervosa. Scientists have observed differences in brain structure and function in people with anorexia[4][8]. Anorexia can cause changes in the brain due to very poor nutrition. This is why it’s not a choice to continue the risky and damaging behavior[2].
People with anorexia have different levels of neurotransmitters (chemical messengers in the brain) like serotonin and dopamine, which can affect appetite, mood, impulse control, and the brain’s reward system[4][8]. There are deficits in dopamine (which affects eating behavior and reward) and serotonin (which affects impulse control), and altered activity in different brain regions[8].
Genetics and family
Genetic correlations exist between anorexia nervosa and certain traits[8]. Having a first-degree relative with an eating disorder significantly raises your risk of also having one[4]. Part of this may be in the genes you inherit from your parents at birth. Part of it may also be in the values and habits you inherit by growing up in your family[4].
Social and peer pressure
Social and professional peer pressure can both be strong forces, especially if your social or professional standing depends on your body image[4]. The success of many professions depends on a person’s weight. Models and actors portray a level of thinness that is difficult to attain, and it is enhanced by makeup and photographic alterations. Athletes in sports such as ballet, long-distance running, and martial arts are pressured to maintain lean body weights to outperform the competition[8].
Media outlets promote diet secrets and weight loss tips in excess. Teenagers can be very judgmental of themselves and each other[4][8].
Psychological factors
Having low self-esteem or feeling that your self-worth depends on controlling your body weight can lay the groundwork for anorexia[4]. Risk factors for eating disorders include mood disorders, personality traits (impulsivity and perfectionism), sexual abuse, or weight-related concerns from family or peer environments[8].
Patients often have co-occurring psychiatric disorders such as major depressive disorder and generalized anxiety disorder[8].
Health risks and complications
Without recognition and treatment, anorexia nervosa can be life-threatening[4]. If left untreated, weight loss can get to a point where people with anorexia are at high risk of serious physical harm or death[2].
Anorexia has the second-highest death rate of any mental illness, surpassed only by opioid overdoses. Most deaths related to anorexia stem from heart conditions and suicide[2]. It has one of the highest mortality rates of any psychological disorder[13].
Long-term anorexia can lead to severe health problems associated with not getting the right nutrients (malnutrition). But these will usually begin to get better once food intake starts improving[5].
Possible complications include[5]:
- Problems with muscles and bones—including feeling tired and weak, osteoporosis, and problems with physical development in children and young adults
- Fertility problems
- Loss of sex drive
- Problems with the heart and blood vessels—including poor circulation, an irregular heartbeat, low blood pressure, heart valve disease, heart failure, and swollen ankles, feet, and legs
- Problems with the brain and nerves—including difficulties with concentration and memory or, less often, seizures
- Kidney or bowel problems
- Having a weakened immune system or anemia
How is anorexia nervosa diagnosed?
If a healthcare professional thinks that you have anorexia nervosa, you may have several tests and exams to pinpoint a diagnosis, rule out medical causes for the weight loss, and check for any related complications[11].
Physical examination
The physical exam includes measuring your height and weight and checking your vital signs (heart rate, blood pressure, and temperature). Usually, the exam also includes checking skin and nails for problems, listening to the heart and lungs, and looking at the stomach area[11].
Laboratory tests
Lab tests may include a complete blood count and more-specialized blood tests to check electrolytes (minerals in the blood) and protein, as well as the function of the liver, kidney, and thyroid. A urine test also may be done[11].
Additional studies
X-rays may be taken to check bone density, check for stress fractures or broken bones, or check for pneumonia or heart problems. An electrocardiogram may be done to look for heart issues[11].
Mental health evaluation
Your healthcare professional likely will ask about your thoughts, feelings, and eating habits. They also may ask you to answer a series of questions about your health[11].
Treatment approaches
You can recover from anorexia, but it may take time and recovery will be different for everyone[5]. With proven treatment, people with anorexia can return to a healthy weight, develop more-balanced eating habits, and reverse some of anorexia’s serious medical and mental health complications[2].
It’s best to treat anorexia nervosa using a team approach. The team includes doctors, mental health professionals, and other healthcare professionals—all with experience in treating eating disorders[11][19]. Your treatment plan will be tailored to you and should consider any other support you might need, such as for depression or anxiety[5].
Talking therapies
If you’re over 18, you should be offered a type of talking therapy to help you manage your feelings about food and eating so that you are able to eat enough to be healthy[5]. Talking therapies that are commonly used to treat anorexia in adults include[5][13]:
- Cognitive behavioral therapy (CBT)
- Maudsley anorexia nervosa treatment for adults (MANTRA)
- Specialist supportive clinical management (SSCM)
Several behavioral treatments for adults exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain[13].
Family therapy
If you’re under 18, you should be offered family therapy[5]. Among adolescents, family-based treatment is considered a first-line behavioral treatment[13]. You may also be offered another type of talking therapy, such as CBT or adolescent-focused psychotherapy[5].
Family therapy is a type of group therapy that encourages the person with the eating disorder to work with family members to try to treat their eating disorder. Family therapy usually involves parents and siblings, but may sometimes include close friends or other family members[18].
Medical care and monitoring
During treatment, you will have regular health checks to look after your physical health[18]. Medical care includes treatment and referrals if necessary for physical health[15].
Nutrition counseling
Treatment may involve nutrition education or working with a registered dietitian to educate about nutrition and meal planning[11][19]. This helps people learn about healthy eating patterns and get back to a healthy weight.
Medications
Although antidepressants provide little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with anorexia nervosa[13]. Your treatment may also involve medicines for mental health disorders[15].
Hospital and inpatient care
Most people with eating disorders will not have to stay in hospital. They are seen as outpatients, which means they visit the hospital for their appointments or any treatments[18]. However, if your life is in danger, you may need to be treated in a hospital emergency department[11].
Some people who have a more advanced or serious eating disorder might need to visit the hospital for longer appointments as a day patient or be admitted to hospital for more intensive support and treatment (known as inpatient care)[18].
Length of treatment
Treatment will take place over several months, so you can get used to the changes slowly. The earlier treatment starts, the better the chances of making a good recovery[18].
Getting help
Getting help and support as soon as possible gives you the best chance of recovering from anorexia[5]. If you think you may have anorexia, even if you’re not sure, see a doctor as soon as you can[5].
It can be very hard to admit you have a problem and to ask for help. It may make things easier if you bring a friend or loved one with you to your appointment[5].
If you’re concerned that a family member or friend may have anorexia, let them know you’re worried about them and encourage them to see a doctor. You could offer to go along with them[18].
You can also talk in confidence to an adviser from eating disorders charity organizations. The National Eating Disorders Association (NEDA) works to advance research, build community, and raise awareness to support the nearly 30 million Americans who will experience an eating disorder in their lifetimes[1]. NEDA provides screening tools for ages 13 and up to see if it is time for professional help[1].
