[icon name=”user” class=”” unprefixed_class=””]    Christina Ripp, MA

Anorexia Nervosa is perhaps the most well-known eating disorder, in part due to the celebrity of some individuals who have suffered and recovered from the disorder. This condition is complex, with behaviors and subtypes that may be expressed differently for each individual case. The following is a general overview of the diagnosis, symptoms, complications, risk factors, treatments, and some misconceptions about Anorexia.

Symptoms:

As described in the DSM 5, the diagnosis of Anorexia relies on three main areas:

Low Body Weight: Limiting food intake which causes one’s body weight to be substantially lower than would be physically healthy; basically this is self-imposed starvation.¹

“Low body weight” means around 15% below a normal and expected BMI for an average adult.²

Fear of Weight Gain: The ideas of gaining weight or getting fat tend to be regarded as worst case scenarios, and are deeply feared. This is a primary motivation for the individual taking steps to prevent any weight gain or to encourage loss of weight¹.

Body Image: Individuals may also have a disordered and biased view of their own bodies, mostly or entirely focusing on “being fat” or areas of the body that are “too big.”

The individual also places a high priority on body size/weight, and assumes that one’s physical body (specifically how thin a person may be) reflects personal value and self-worth. They often see the ability to lose weight or maintain a low weight as a major success and source of pride¹.

There are two main expressions of the disorder, both named quite clearly for their differences¹:

The Restricting type: Individuals with this type tend to severely limit how much food they eat; they may or may not over-exercise.

The Binge-eating/purging type: Individuals with this type may binge (eat a lot of food in a small amount of time) and/or purge (different ways of quickly getting rid of body fluids, such as vomiting, using laxatives, diuretics, or enemas). This type of Anorexia does share some symptoms with Bulimia Nervosa, but the main difference between the two disorders is the degree to which binging behaviors occur compared to restricting behaviors: Most people with Bulimia tend to stay at a normal weight, while people with Anorexia tend to be very underweight¹.

These two types are not rigid labels; a person with Anorexia may move from one type to the other, back and forth, etc¹.

Common Behaviors Related to Anorexia

The Center for Eating Disorders at Sheppard Pratt offers a list of behaviors which might typically be seen in people with Anorexia, and which may be a helpful reference to concerned family members⁸:

• Checking body size/weight/shape frequently, such as compulsively checking weight, appearance in a mirror, measuring waist circumference, etc…

• Noticeable and significant weight loss
• Making statements about “feeling fat” or expressing worry about weight despite being at a low weight

• Exercising too frequently; strictly sticking to exercise schedule even when adverse conditions are present (i.e. being sick, injured, poor weather conditions, etc…)

• Minimizing or not admitting to feeling hungry
• Rigidly counting and adhering to specific number of calories

• Creating and sticking to rituals around food (such as chewing a certain number of times, taking only small bites, eating foods on the plate only in a specific sequence…)

• Finding reasons to get out of situations in which food is present (for example, avoiding dinnertime, avoiding the cafeteria…)

Physical Complications

To determine severity of each particular case, professionals typically look at how underweight the person is, specifically by looking at their BMI (Body Mass Index)¹. The physical complications caused by Anorexia are numerous and involve the whole body. The majority of the physical complications can be reversed if the individual receives treatment and/or medical care⁵. Most commonly, individuals with Anorexia may suffer from:

Cardiovascular problems: Severe undernourishment can cause various heart-related problems, such as: Low blood pressure; abnormalities in heart rhythm (especially having an abnormally slow heartbeat); and at the most severe end of the continuum, heart failure⁶. The person may feel a lack of energy, feel tired most of the time, and/or feel body weakness⁷.

Skeletal problems: Osteoporosis/loss of bone density- the bones can become weak⁷.

Physical Appearance issues: Besides losing body fat, the individual will also likely lose body muscle, which contributes to feeling weak ⁷. The hair and nails may become brittle, while the skin becomes dry and may grow “lanugo,” a light coat of hair⁶.

Gastrointestinal problems: Having slowed down the digestive system by not eating enough, extreme constipation can occur⁷. With the Binge-eating/purging type, erosion to the enamel of the teeth is likely, and a swelling of the salivary glands may be seen, as related to vomiting⁶.

Reproductive problems: If the individual is female, she may experience a loss of her period (Amenorrhea), or a delay in the start of her period⁷. Anorexia can contribute to infertility, as well as miscarriages and problems with pregnancy⁷.

Mortality: Individuals have an increased risk of dying, and increased risk of suicide³. About one in five deaths related to Anorexia result from suicide³.

Causes and Risk Factors

A specific and direct cause of Anorexia is not known, but professionals can pinpoint some life and environmental factors that tend to go along with an increased risk of developing Anorexia. Some significant risk factors which can impact the development of eating disorders, as summarized by the National Eating Disorders Association are¹⁰ :

• Poor self-esteem
• Consistently having negative emotions such as depression, anxiety, feeling lonely, problems with anger.
• Having a hard time communicating or expressing feelings in a healthy way
• Having been bullied, made fun of regarding one’s weight, body size

• Having experienced discrimination, for example related to one’s weight, culture, ethnicity, and/or race, and any other forms of discrimination.

• Suffering from sexual and/or physical abuse

• Living in a culture which emphasizes the value of being slender, and which only accepts thinness as the standard of beauty.

In addition, the DSM 5 lists the following as risk factors¹:

• There does appear to be a genetic component to the disorder: Having a first degree relative who has Anorexia puts a person at higher risk.

• Having a career or job which places a high priority on being thin (such as modeling, ballet, and gymnastics, for example)

• In childhood, having an anxiety disorder or having had a tendency to obsess about things (such as perfectionism, being overly focused on details)

Treatment

People with Anorexia often work to hide their disordered eating and weight-related behaviors in an effort to continue restricting their intake without the interference of medical or mental health help². The consequences of Anorexia can be severe, which necessitates treatment for many sufferers: Anorexia not only has the highest death rate of all eating disorders³, but also the highest death rate of all mental illnesses⁴. Often it’s the individual’s family and/or friends who initiate treatment.

Treatment itself may need to be multi-approach, depending on the individual’s level of need of care. Common available treatments include:

Inpatient Hospital Care¹⁰: Inpatient treatment (staying in a care facility overnight over a period of time) may be necessary to help the individual gain weight. Weight gain is the primary goal of inpatient care; it is important to note that even when some weight is restored, the person will still need treatment to work on the psychological components of the illness. Gaining back much-needed weight is only one step in the process of recovery.

Psychotherapies and Mental Health Care¹⁰: There are a multitude of counseling and mental health therapy approaches that have been shown to be successful with Anorexia – there is no single best approach. Commonly used therapies include:

• Cognitive Behavior Therapy (CBT),
• Cognitive Analytic Therapy (CAT)
• Behavior Therapy,
• Interpersonal Psychotherapy,
• Family therapies and interventions,
• Motivational Interviewing
• Nutrition counseling

Eating disorder treatment centers are located across the United States: If you think you or someone you love may have an eating disorder, feel free to call the nearest eating disorder treatment center and ask for information. If you do not live near one of these centers, you can also call mental health clinics in your area and ask about therapists who specialize in helping individuals with eating disorders.

What if someone doesn’t fit this diagnosis, but you know there’s still a problem?

It is important to note that there are many people with disordered eating behaviors who might not fit the descriptions of Anorexia or Bulimia, yet they still most definitely have an eating disorder. The DSM 5 has a classification named “Other Specified Eating and Feeding Disorders,” in an attempt to help professionals catch cases of eating disorders which do not fit neatly into either Anorexia or Bulimia⁷. As the Center for Eating Disorders at Sheppard Pratt states, it’s still important to seek help even if you don’t have Anorexia or Bulimia, because all disordered eating behaviors can cause legitimate and serious health problems⁷.

Myths vs. Facts

Myth: Anorexia only occurs in women.

Fact: It’s important to be aware that it’s not only women who suffer; Men and women both develop the condition. We know that Anorexia is significantly more common in women than in men, with about ten to fifteen percent of diagnosed cases in men⁷.

Myth: Anorexia only occurs in teenagers.

Fact: While the highest risk age group for developing Anorexia is between ages 15 to 19², the disorder is seen in all age groups⁷.

Myth: Anorexia only occurs in white middle class people.

Fact: Anorexia occurs mostly in developed countries, but we don’t really know how often it occurs in lower-income countries. The disorder is multicultural – it occurs across cultures and ethnicities, although the expression and associated behaviors may differ depending on the person’s culture¹.

References

1. American Psychiatric Association (2013). Feeding and eating disorders In Diagnostic and Statistical Manual of Mental Disorders (5^th ed). Washington, DC: Author.

2. Smink, F.R.E., van Hocken, D., Hock, H.W. (2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports. 14, 406-414. doi: 10.1007/s11920-012-0282-y.

3. Arcelus, J., Mitchell, A. J., Wales, B., & Nielson, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. JAMA Psychiatry, 68(7), 724-731. doi:10.1001/archgenpsychiatry.2011.74.

4. Harris EC, Barraclough B. (1998) Excess mortality of mental disorder. British Journal of Psychiatry ,173, 11-53

5. Brown, C., & Mehler, P. (2015). Medical complications of anorexia nervosa and their treatments: An update on some critical aspects. Eating and Weight Disorders –Studies on Anorexia, Bulimia, and Obesity. doi: 10.1007/s40519-015-0202-3.

6. Sharp, C.W., & Freeman, C.P.L. (1993). The medical complications of anorexia nervosa. British Journal of Psychiatry, 162, 452-462.

7. The Center for Eating Disorders at Sheppard Pratt. (2015). “Anorexia nervosa: Health consequences and medical complications of anorexia nervosa.” Retrieved from http://eatingdisorder.org/eating-disorder-information/anorexia-nervosa/.

8. The Center for Eating Disorders at Sheppard Pratt. (2015). “Signs and symptoms of anorexia nervosa.” Retrieved from http://eatingdisorder.org/eating-disorder-information/anorexia-nervosa/.

9. National Eating Disorders Association. “Factors that may contribute to eating disorders.” Retrieved from http://www.nationaleatingdisorders.org/factors-may-contribute-eating-disorders.

10. British Psychological Society. (2004). Treatment and management of anorexia nervosa. In Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders (pp.1-51). Leicester, UK: Author.