What Is Anorexia Nervosa?

Anorexia nervosa, also known simply as anorexia, is an eating disorder characterized by weight loss, difficulties maintaining an appropriate body weight, and an intense fear of weight gain.

People with anorexia generally restrict the number of calories and the types of food they eat. Often they eat so little that they cannot sustain basic bodily functions, leading to serious health complications and even death. Those with this eating disorder may also think that they are overweight even when they are thin (distorted body image).

Anorexia nervosa can occur across genders, ages, races, ethnicities, and socioeconomic statuses. This eating disorder increases a young person’s risk of dying by tenfold, and it has one of the highest mortality rates among mental disorders and a high relapse rate.

Symptoms

Symptoms of anorexia can be physical, behavioral, and emotional. Research suggests dieting is the most common onset symptom in anorexia. A person with anorexia typically looks very thin and may not act like themselves, but weight loss may initially go unnoticed if they wear baggy clothes or extra layers to hide it.

Behavioral 

Behavioral symptoms are often the first early warning signs that can be noticed by loved ones, and they include:

• Talking about weight or food all the time
• Not eating or eating very little
• Refusing to eat in front of others
• Not wanting to go out with friends
• Making themselves throw up
• Taking laxatives or diet pills
• Exercising a lot

People with anorexia nervosa commonly restrict their diet and exclude any foods they consider too caloric. They may skip meals altogether. They also commonly develop mealtime rituals, such as cutting food into tiny pieces, patting liquid off with napkins, or picking food apart.

Those with this eating disorder also often engage in excessive physical activity despite bad weather, illness, or injury.

Emotional 

These symptoms may be more obvious to the individual, but like other symptoms, are often met with minimization or denial (especially in adolescents).

Emotional symptoms of anorexia include:

• Anxiety
• Depression and suicidal thinking
• Moodiness

Physical

Physical symptoms usually do not appear right away. They emerge over time as a result of ongoing starvation where insufficient nutrients are supplied and utilized as the body attempts to conserve reserves in order to survive.

The physical symptoms of anorexia include:

• Confused or slow thinking
• Poor memory or judgment
• Thin, brittle hair and nails
• Feeling cold all the time
• Feeling faint, dizzy, or weak
• Feeling tired or sluggish
• Irregular periods or never getting a period
• Dry, blotchy, or yellow skin
• Growth of fine hair all over the body (called lanugo)
• Severe constipation or bloating
• Weak muscles or swollen joints

Causes

It’s not clear what causes anorexia, but researchers think this eating disorder may be a result of a combination of genetic, biological, and environmental factors.

One recent theory is that anorexia is driven by abnormalities in the food reward pathway, and there are some who believe release of endorphins in starvation play a role in anorexia.

Eating disorders, including anorexia, have also been associated with abnormal neurotransmitter systems involving serotonin, dopamine, and other neurochemicals.

Risk Factors

Researchers have identified several risk factors for anorexia, including:

• Body image dissatisfaction
• Perfectionism and behavioral inflexibility
• Childhood feeding problems
• Family history of an eating disorder or another mental disorder
• History of an anxiety disorder
• History of dieting
• Weight stigma (discrimination or stereotyping based on a person’s weight)
• Teasing or bullying
• Limited social network or support system
• Type 1 diabetes (a significant number of women with type 1 diabetes have disordered eating)

Parenting style, household stress, and parental discord may also contribute to anxiety and personality traits that are risk factors for anorexia. An emphasis on success and external rewards may lead to overly high expectations in children, who may then try to be successful with something they can control: regulating what they eat and how they look. 

Diagnosis

Anorexia is diagnosed by using the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

The criteria include:

• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of the age, sex, developmental trajectory, and physical health (less than minimally normal/expected)
• Intense fear of gaining weight, or engaging in persistent behavior that interferes with weight gain even when the person is at a significantly low weight
• Disturbed by one’s body weight or shape, or persistent lack of recognition of the seriousness of their low body weight

Specifications will also be made between restricting (absence of purging behavior) and binge-eating/purging types of anorexia and between partial remission and full remission. 

Partial remission means after full criteria are met, a low body weight has not been met for a sustained period of time, but at least one of the following two criteria are still met: intense fear of gaining weight or becoming obese, or behavior that interferes with weight gain or disturbed by weight and shape. Those who are in full remission have not met any of the criteria for anorexia for a sustained period of time.

Treatment

The best chance at full remission from anorexia comes from a multifaceted approach to treatment, which may include nutritional counseling, psychotherapy, and medications to control anxiety and depression symptoms. In severe cases, hospitalization may be necessary. 

Nutritional Counseling

The main initial focus of treatment for anorexia is nutritional support and weight restoration. A registered dietitian will help you eat healthy to reach and maintain a healthy weight. Reaching a healthy weight is a key part of the recovery process so that your body’s biology, including thoughts and feelings in your brain, work correctly. It can also help in developing healthier relationships with food and establishing normal eating patterns.

Some people may need to be hospitalized or participate in a residential treatment program to make sure they eat enough to recover. Hospitalization may be required if someone’s medical status has been significantly compromised by their weight loss and malnutrition.

The key goals of nutritional counseling for anorexia include:

• Weight restoration and maintenance
• Developing neutrality toward food through redeveloping intuitive understandings of hunger, fullness, and satiety
• Regulation of phosphate levels in blood

Psychotherapy

Psychotherapy for anorexia aims to help an individual transform their thinking and behavior patterns while developing a healthy attitude toward weight and food, as well as developing healthy coping mechanisms for life stressors.

Common forms of psychotherapy used to treat anorexia include:

• Cognitive behavioral therapy (CBT) addresses distorted views and attitudes about weight, shape, and appearance, and encourages practices of behavioral modification.
• Dialectical behavior therapy (DBT) is CBT techniques plus mindfulness and other emotional management strategies. This therapy helps the individual develop new skills to handle negative triggers and insight to recognize triggers or situations where a non-useful behavior may occur. Specific skills include building mindfulness, improving relationships through interpersonal effectiveness, managing emotions, and tolerating stress.
• Acceptance and commitment therapy helps a person embrace their thoughts and feelings, rather than fighting them or feeling badly about them.
• Cognitive remediation therapy helps people develop cognitive strategies and improve their thinking skills by practicing mental exercises.
• Family-based therapy (FBT), also called the Maudsley Method, involves family-based refeeding, which means putting the parents of a child or adolescent or their family in charge of making sure the appropriate nutritional intake is met by the person with anorexia. It is one of the most evidence-based methods to physiologically restore health to an individual with anorexia nervosa who is under 18 years of age.
• Interpersonal psychotherapy helps a person resolve an interpersonal problem area. Improving relationships and communications, as well as resolving identified problems, have been found to reduce eating disorder symptoms.
• Psychodynamic therapy involves looking at the root causes of anorexia nervosa, the patient’s true underlying needs and issues, as the key to recovery.

Medication

There is no medication that can cure anorexia, but antidepressants and anti-anxiety medications may be used in conjunction with therapy to help reduce symptoms and treat coexisting conditions like obsessive compulsive disorder. For example, antidepressants, including selective serotonin reuptake inhibitors (SSRIs), may help mitigate symptoms of depression and suicidal ideation in patients with anorexia nervosa. 

There may also be a role for atypical antipsychotics like Zyprexa (olanzapine), which may be able to help with aspects of distorted thinking in anorexia and can potentially contribute to weight gain. Often patients with anorexia are reluctant to take any medication that has weight gain as a side effect.

Family or Group Therapy

Family support is very important to treatment success for anorexia. Family members need to understand the eating disorder and recognize its symptoms. People with anorexia might benefit from group therapy, where they can find support and openly discuss their feelings and concerns with others who share similar experiences and problems.

Coping

Recovery from anorexia takes time and effort, and it can be frustrating at times, especially when you have a relapse. Developing healthy coping skills can help you stay focused on recovery even when times are difficult.

Join a support group where you can talk to others who have had similar experiences. The National Alliance on Mental Illness runs free, peer-led support groups for people who have a mental disorder, and you can find one in your local area through the organization’s online directory.

Other strategies for coping with anorexia include:

• Write about your feelings in a journal throughout the day.
• Grow your support system.
• Discuss your needs with people you live with. There may be changes the other person can make to help you.
• Note mealtimes and what you eat. If you record your level of satiety and urges to binge, restrict, or purge, you may learn if there are foods or a length of time between meals that trigger you.
• Add positive statements when you talk to yourself about your body and weight, gradually letting go of the negative.
• Let yourself have needs and limits in your work or personal life. Holding back anger and resentment and stifling your needs leads to increased stress.
• Change the subject when other people talk about food, weight, or body size and shape.
• Stay away from social media and other channels.
• Practice self-care by doing things you enjoy and hanging out with people you feel safe with.

A Word From Verywell

Anorexia can trick you into feeling like you’re in control when you’re actually being controlled by a mental disorder. It’s important to ask yourself the hard questions about how you feel about your body, eating patterns, and how much time and effort you’re dedicating to losing weight.

Dieting can often lead to the restrictive and purging behaviors characteristic of anorexia, and this is not your fault. If you think you have a problem with body image or eating, talk to your friends and family and seek help from a mental health professional. With continued effort, you can make a full recovery and recognize your personal relapse triggers before they take control of your life.