An Overview of Anorexia Nervosa

Anorexia nervosa is a highly debilitating eating disorder. Even though it may be the most recognized eating disorder, most people cannot tell you about the specific causes, symptoms, and treatments of anorexia nervosa.

Many people believe that it is easy to tell if a person has anorexia because they will look emaciated, but the truth is that you can appear healthy and still be suffering. Due to its serious consequences, it is critical to learn how to recognize it and intervene.

What is Anorexia Nervosa?

Anorexia Nervosa is an eating disorder characterized by abnormally low body weight, an intense fear of gaining weight, and a distorted perception of weight. Controlling body appearance and weight is of utmost importance to someone suffering from anorexia. To achieve these goals, people will place severe restrictions on food intake and practice unhealthy purging behavior.

The Causes of Anorexia

Although the exact cause of anorexia is unknown, it is likely a mix of biological, psychological, and environmental variables.

Biological Factors

Anorexia is often thought of as primarily a female disorder. Almost 1% of females will develop anorexia during their lifetime. Females are more than twice as likely to be diagnosed with anorexia as males.

Unfortunately, that minimizes the threat to males and may lead to the under-diagnosis of a serious problem for boys and men. Besides a person’s sex, genetics also plays a role. There is a higher likelihood of developing the disorder if a close family member has previously had it. Further, a link has been found between neurotransmitter levels and eating disorders. Similar to depression, low amounts of serotonin and norepinephrine have been associated with the development of anorexia.

Psychological Factors

Several psychological factors are associated with anorexia:

Comorbid Disorders – People diagnosed with anorexia often have other psychological disorders. Particularly common are mood disorders, anxiety, and obsessive-compulsive disorder (OCD). Although it is impossible to say these disorders are definitive causes of anorexia, there is likely an ongoing interaction between these problems and anorexic behavior.

Perfectionism – Being a perfectionist certainly has its advantages but people who are perfectionistic also tend to be less psychologically flexible and more controlling. In the case of anorexia, perfectionistic individuals frequently believe that their body must look a certain way to satisfy their rigid expectations. As a result, they set an unreasonable standard that fuels the behavior necessary to develop symptoms of anorexia.

Low Self-Esteem – A lack of self-esteem seems to be a contributor to anorexia and other eating disorders. Someone who feels good about themselves is less likely to feel they need to look a certain way or maintain a specific body weight. In contrast, people with poor self-image may pinpoint their weight as an area that needs to be drastically altered. In general, people with poor self-esteem are more vulnerable to peer pressure and societal expectations involving appearance.

Lack of Support – Everyone needs support to deal with difficult issues. This is even more true for adolescents and young adults, who are solidifying their identity and prone to insecurities. It is easy to develop maladaptive thoughts about weight and body image when you don’t have someone with whom to talk about your problems. Additionally, without support, individuals have no one to notice their anorexic symptoms and intervene helpfully.

Environmental Factors

Environmental factors appear to play a large role in the development of anorexia.

Critical Families – Although usually well-meaning, some parents and family members may be critical of weight gain and certain body types. The family has a great impact on our behavior. Certain people may internalize those negative messages and feel they have to do what is necessary to meet family expectations.

Peer Pressure – Similarly, there is frequently a lot of pressure to look a certain way to fit in with a group of friends. Younger people may be particularly susceptible to outside influence, as they are still forming their identities. Almost nothing is more important to a teenager than a sense of belonging and they will do almost anything to feel included.

Sexual Abuse – Sexual abuse can give rise to confusion and poor self-esteem. Because sexual abuse involves bodily touching, it contributes to questions about body image and appropriate body usage. In addition, people who have been abused often feel violated and will go to great lengths to regain a feeling of control over their bodies.

Career Advantage – Certain careers demand a thin body. If you are a dancer, athlete, model, or entertainer there is almost a prerequisite of looking thin. Furthermore, people who are of average weight or less tend to get hired and promoted more often than overweight people. The message is clear: If you want a successful career it is better to be thin.

Life Changes – Change is difficult for almost everyone. People cope in different ways, some healthier than others. Negative emotions can contribute to overeating, dieting, and purging behavior. When life transitions occur, it is often unexpected, and people feel out of control. Food restriction is one way people use to take back a feeling of control.

Western Stereotypes – One of the most influential environmental factors is how Westernized countries portray beauty. Even though this is slowly changing, most famous people are thin. Growing up in Western society, it would be almost impossible for people not to internalize the idea of beauty as being average weight or less. Athletes, models, and entertainers are put on a pedestal as the idealized version of men and women. Rarely are these people overweight. It would be fair to say that we have an unhealthy cultural obsession with being thin.

Signs and Symptoms of Anorexia

The average age of onset of anorexia is in late adolescence/early adulthood but it can occur at almost any time after puberty. Here are warning signs and symptoms to help you identify its occurrence.

Before someone develops full-blown symptoms, there may be warning signs that can be recognized by the individual or loved ones, including:

• Frequently looking at yourself in the mirror
• Constantly worrying about dieting, food, and weight
• Complaining a lot about being “fat”
• Pretending you’re not hungry when you really are
• Refusal to eat certain foods, including groups of “bad for you”
• You are exercising religiously
• Avoiding friends
• Wearing baggy clothing
• Loss of interest in your usual activities
• Lying about food consumption
• Avoiding eating in public

Symptoms of anorexia can be divided into physical, emotional, and behavioral. Please note that only some of these may occur but a preponderance of symptoms is more likely to indicate a problem related to anorexia.

Physical Signs

• Dramatic weight loss
• Gastrointestinal problems (e.g., constipation, stomach cramps, acid reflux, etc.)
• Difficulty concentrating
• Concerning medical findings (e.g., low thyroid and hormone levels, anemia, low potassium, low blood cell counts, slow heart rate)
• Dizziness
• Fainting
• Frequently feeling cold
• Sleep problems
• Menstrual troubles (e.g., amenorrhea, irregular periods, etc.)
• Cuts and calluses across the top of fingers from induced vomiting
• Dental problems, such as cavities and tooth sensitivity
• Teeth discoloration

Emotional Signs

• Mental preoccupation with all things concerning weight, food, and dieting
• Makes frequent comments about feeling “fat” or overweight despite weight loss
• Denies feeling hungry
• Consistently makes excuses to avoid mealtimes or situations involving food
• Expresses a need to exercise
• Becomes secretive
• Concerned about eating in public
• Plans social interactions rather than being spontaneous
• Resists maintaining bodyweight appropriate for their age, height, and sex 
• Has intense fear of weight gain
• Weight and/or shape has a large influence on self-image
• Denial of the seriousness of low body weight
• Has a strong need for control
• Shows inflexible thinking
• Restrained emotional expression
• Low perceived self-efficacy

Behavioral Signs

• Severely restricting food intake through dieting or fasting
• Bingeing and self-induced vomiting to get rid of food, which may include the use of laxatives, enemas, diet aids, or other products
• Dresses in layers to hide weight loss and stay warm
• Cooks meals for others without eating
• Maintains an excessive and rigid exercise regimen despite any interfering circumstances (e.g., work, family, and social commitments)
• Develops food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate)

Diagnosing Anorexia

According to the Diagnostic and Statistical Manual (DSM-5), to receive a formal diagnosis of anorexia nervosa three criteria need to be met:

1. Food restriction results in a weight that is significantly below the average weight for their age, sex, and height.
2. Fear of gaining weight or becoming fat.
3. Distorted view of own weight and body shape, resulting in an inaccurate view of own weight and minimization of problematic food restriction. For example, this may result in someone thinking they are fat when they are severely underweight.

Additionally, there are two subcategories of anorexia:

Restricting Type:

Restricts without engaging in binging and purging.

Bing-eating/purging Type:

Regularly engages in binge eating and purging. Commonly, this takes the form of vomiting or ingesting a laxative.

Diagnostic Dilemma: Anorexia vs. Bulimia

Although eating disorders may share common characteristics, it is important to be able to differentiate between them for treatment purposes. Anorexia nervosa and bulimia nervosa look very similar and can be difficult to diagnose. They both consist of purging food after eating. However, there is one major way to distinguish this type of anorexia from bulimia. In bulimia, unlike anorexia, there are no criteria for weight loss. That does not mean weight loss will not occur in bulimia but it is not necessary for a diagnosis. Anorexia, in contrast, cannot be diagnosed without below-average weight loss.

Treatment Options for Anorexia

Treatment for anorexia usually involves an interdisciplinary approach focusing on both medical and psychological aspects of the disorder. The level of treatment depends upon the severity of the disorder. While some people may display only warning signs, others may be near death and require immediate intervention.

Hospitalization

In severe cases, hospitalization may be necessary. This may occur for medical or psychiatric reasons. People with anorexia can become dangerously unhealthy and underweight and may require hospital care before they are deemed safe for a less restrictive environment. Feeding the patient to return them to a non-dangerous weight and nutrition level is always the priority. In addition, hospitalization for suicidal ideation and self-harm behavior is possible. It has been found that people with anorexia are 31 times more likely to commit suicide than others. For these reasons, it is one of the most deadly psychiatric disorders.

Residential

There are many residential programs for eating disorders. This is a step down from hospitalization but still highly intensive. Residential settings are longer-term than hospitalization and can provide the necessary supervision, psychotherapy, and medical assistance.

Outpatient

When out of immediate danger and able to function without around-the-clock supervision, the following types of outpatient treatment are available:

Family-Based Treatment (FBT)

Commonly used with anorexia (and bulimia), this form of treatment involves the family as essential members of the treatment process. The focus is on returning people to normal body weight. Family members help the individual learn healthy eating habits and offer needed support.

Family involvement is often critical in anorexia treatment. Some individuals with anorexia deny the severity of the problem and only the encouragement of family members keeps them motivated and on a positive track. FBT is one of the most studied therapies and has consistently proven to be successful. This is not all that surprising due to the critical role family plays in the lives of most people, especially teenagers and young adults.

Enhanced Cognitive Behavioral Therapy (CBT-E)

CBT is commonly used with adults who display disordered eating; it is also used with teenagers but its effectiveness is not as well-studied. The reasoning for the use of CBT is that people with eating disorders exhibit distorted thinking about body weight and put an overemphasis on the importance of being thin. CBT addresses these issues through regulating eating patterns, cognitive restructuring of distorted thoughts, and recording food intake. Nutritional education and family involvement are also commonly employed.

Adolescent Focused Therapy (AFT)

AFT is primarily targeted at adolescents, who make up a large part of the anorexic population. It is an individual psychotherapy rooted in psychodynamic principles. Some of the goals of AFT are improving autonomy, assertiveness, and self-efficacy. The rationale of this approach comes from the idea that adolescents develop disordered eating because they feel out of control and their personal development may be stunted by maladaptive parental involvement.

Treatment includes encouraging the youth to gain weight and to eat normally as a way to increase self-control and mastery. Parent meetings may also be included as a way to improve parent-child interactions and support individual treatment.

Nutritionist and Doctor Meetings

There is an important medical component to anorexia. Maintaining a healthy weight and proper nutrition is a primary focus. A doctor and nutritionist are frequently employed as part of a treatment team to ensure that the medical aspects of anorexia are receiving the necessary attention. For example, a dietician may work with a client to plan a healthy menu. Or a doctor might conduct regular weight checks and bloodwork to check on physical health as well as provide external reinforcement and accountability.

Medication

There is no medication specifically developed to treat anorexia. However, because anorexia, depression, and anxiety often coincide, a doctor may prescribe an anti-depressant medication to treat it. While anti-depressants have not been shown to help with the particular symptoms of anorexia they do help with anxiety and depressive symptoms. Further, there has been some evidence that selective serotonin reuptake inhibitors (SSRIs) may help with the binging-purging behaviors of bulimia.

Getting Help for Anorexia Nervosa

Our world idealizes thinness. This can make it difficult to realize when someone you know has a problem with anorexia nervosa. Regrettably, there is a narrow line between healthy and unhealthy weight-loss behavior. Someone may be congratulated for restrictive dieting and losing significant weight. Although there are certainly self-help activities that a person can perform to help with anorexia, it is a disorder that likely requires professional assessment and treatment.

Often, a person with anorexia has to be pressured into seeking help because they are in a state of denial. In addition, many people go to great lengths to keep their unhealthy eating behavior a secret from others. As with most disorders, the longer it goes unchecked the more serious the consequences. If you or a loved one is exhibiting warning signs or symptoms of anorexia it is crucial to seek help immediately. With effort and determination, you can overcome the silent suffering of anorexia nervosa.

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Sources:

• Eating disorders. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/eating-disorders
• Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders. The Lancet, 361(9355), 407–416. https://doi.org/10.1016/s0140-6736(03)12378-1
• Giel, K. E., Thiel, A., Teufel, M., Mayer, J., & Zipfel, S. (2010). Weight bias in work settings – a qualitative review. Obesity facts, 3(1), 33–40. https://doi.org/10.1159/000276992
• Volpe, U., Tortorella, A., Manchia, M., Monteleone, A. M., Albert, U., & Monteleone, P. (2016). Eating disorders: What age at onset? Psychiatry Research, 238, 225–227. https://doi.org/10.1016/j.psychres.2016.02.048
• Machado, P. P., Grilo, C. M., & Crosby, R. D. (2017). Evaluation of the DSM-5 Severity Indicator for Anorexia Nervosa. European eating disorders review : the journal of the Eating Disorders Association, 25(3), 221–223. https://doi.org/10.1002/erv.2508