Anorexia Nervosa: Signs, Symptoms, & Treatments

What Is Anorexia Nervosa?

Anorexia nervosa is an eating disorder characterized by restriction in food intake, fear of gaining weight, and altered perception of one’s weight or shape.¹ People with anorexia nervosa are typically significantly underweight and, despite losing weight, they still fear becoming fat.¹ Some may have obesophobia (fear of gaining weight) that causes anorexia or that occurs at the same time as anorexia. Sometimes, individuals may use various techniques to assess their shape and weight, such as excessive weighing, measuring body parts, and body checking.¹

Anorexia nervosa typically begins in adolescence or young adulthood. For many young adults, the onset of the disorder happens during a stressful life event such as their first time leaving for college.¹ People who have obsessional traits in childhood or exhibit anxiety symptoms are at increased risk of developing anorexia nervosa.¹

How Common Is Anorexia?

Anorexia nervosa is one of the lesser-common eating disorders. Rates vary for anorexia, but some research indicates around 1.2% of people 15 and older meet criteria at some point in their lifetimes.² Anorexia nervosa in males is far less common than in females, with around a 10:1 ratio.¹ It most commonly presents in cultures where thinness is valued, including occupations such as modeling and certain sports (sometimes called anorexia athletica).¹ It is more common in high-income countries, such as the United States and European countries.¹

Types of Anorexia Nervosa

There are two subtypes that are used to distinguish between different eating patterns noted in people with anorexia nervosa, namely restricting and binge-eating/purging.

The two subtypes of anorexia are:

1. Anorexia Nervosa Restricting Type

People with the restricting type of anorexia display incredibly restrictive patterns of eating. They may refuse to eat certain types or categories of food (like meat or high-fat food), or they may consume very small portions or only eat low calorie foods. People with the restricting type of anorexia tend to not meet their daily caloric and nutritional needs, placing them at high risk of malnutrition and extreme weight loss.

Behaviors to lose weight or prevent weight gain among the restricting type of anorexia include:

• Fasting/food restriction: People may fast or greatly restrict their eating following a binge. They may follow a strict diet in which they only eat certain low-calorie foods or avoid certain types or groups of food.
• Compulsive exercise: People may engage in compulsive exercise patterns. The exercise might be so excessive that it places them at risk for exhaustion, injury, or dehydration.
• Weight loss supplements: People may abuse weight loss supplements or any prescription or over the counter medications that have appetite suppressant effects or that claim to increase metabolism.

2. Anorexia Nervosa Binge-Eating/Purging Type

People with the binge-eating/purging anorexia display behaviors typically associated with bulimia nervosa. This subtype involves a pattern of binge-eating, or eating large amounts of food in a short amount of time, resulting in feeling overly full, uncomfortable, and guilty. To achieve weight loss or prevent weight gain, they may purge by vomiting or using laxatives/diuretics. Some people with anorexia purge after eating small amounts of food.

Behaviors to lose weight or prevent weight gain among the binge/purge type include:

• Laxative or diuretic use: Someone may engage in laxative abuse (sometimes in dangerously large doses) to attempt to hasten the digestive process and avoid weight gain. Some use diuretics to prompt the loss of water weight.
• Vomiting: People may force themselves to vomit after eating to avoid metabolizing food or because they feel scared, guilty or upset about food they have just consumed.

Anorexia Vs. Bulimia

The primary difference between anorexia and bulimia is whether a person is underweight. If they are, they are more likely to be diagnosed with anorexia, but if they are not underweight, or even overweight, they are more likely to be diagnosed with bulimia. Differentiating between anorexia vs. bulimia is much easier when a person does not binge eat and only engages in restrictive behaviors, which indicates the restricting subtype of anorexia.

Approximately 20-40% of people diagnosed with an eating disorder don’t meet full criteria for anorexia or bulimia and are diagnosed with an “other specified feeding or eating disorder” (OSFED). This diagnosis is reserved for people who clearly present with disordered eating patterns that impair their functioning but fail to meet one of the requirements of the criteria for anorexia, bulimia, or binge eating disorder.

Anorexia Nervosa Symptoms

All psychological disorders, including anorexia, are diagnosed using a standardized set of criteria outlined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5).

According to the DSM, the symptoms of anorexia nervosa include:¹

• Restriction of food intake leading to weight loss or lack of weight gain and resulting in a low body weight
• Intense fear of gaining weight
• A distorted view of one’s body (e.g., an underweight person thinking they are fat) or beliefs about food intake (e.g., believing one meal will lead to weight gain)

Warning Signs of Anorexia Nervosa

Anorexia manifests as changes in a person’s eating behavior as well as other physical and emotional indicators. If someone is overly restricting their food, skipping meals, talking about their body negatively, or losing weight quickly, these are all signs of anorexia.

Behavioral Signs of Anorexia

Behavioral signs of anorexia include food restriction, excessive calorie tracking, avoidance of social situations involving food, and rigid eating routines.

Behavioral indicators or signs of anorexia may include:

• Having many food restrictions or strict dietary needs
• Making excuses to not eat (e.g., allergies or health issues)
• Needing to review nutritional information for foods before consuming it
• Excessive tracking of calories or food intake
• Avoidance of social situations involving food
• Skipping meals or having unusual eating schedules
• Being overly concerned about weight loss, diet, or exercise
• Being overly concerned with appearance or body image
• Rigid and inflexible eating preferences and routines
• Deceptive eating patterns like hiding or lying about food intake
• Going to the bathroom frequently after eating
• Regular use of laxatives, appetite suppressants, or weight loss supplements
• Body checking behaviors, including frequent weighing, measuring, or mirror gazing
• Excessive exercise routines followed even when sick, injured, or in bad weather
• Strange eating habits like cutting food in small pieces, blotting with napkins, or separating food

Physical Signs of Anorexia

Certain physical changes can also indicate anorexia. The most obvious physical sign of anorexia is weight loss, which can be extreme. People with anorexia might become defensive or dismissive when others express concern about their low body weight. To others, people with anorexia often appear grossly underweight or sick.

It’s worth noting that not all individuals with the disorder are clinically underweight. Being clinically underweight used to be a required symptom for anorexia, but has since been revised to account for the growing number of individuals who have the disorder but have a normal body mass index (BMI).

As anorexia progresses, low weight and/or a lack of adequate nutrition and calories can lead to other physical changes and health complications, including:

• Hair loss
• Amenorrhea (loss of menstrual period for women)
• Fatigue
• Pale dry skin
• Brittle nails
• Hand calluses
• Growth of excessive body hair
• Constipation
• Increased sensitivity to cold temperatures
• Loss of sexual drive and interest
• Gum disease, stained teeth, and tooth decay (particularly in the binge-purge subtype)

Emotional Signs of Anorexia

People with anorexia sometimes also develop changes in their mood and mental health, resulting in behaviors like withdrawal, anxiety, and depression.

Emotional warning signs of anorexia include:

• Withdrawal from friends or family
• Rigid routines and the need for things being a certain way
• Sadness or depression
• Increased anxiety
• Irritability
• Increased self-criticism
• Low self-esteem
• Lowered stress tolerance

What Causes Anorexia?

Like all mental health disorders, there is not a singular cause for anorexia. A complex combination of biological and environmental factors are thought to place some people at higher risk than others for developing the disorder.

Genetics

Most mental health conditions are believed to have a genetic involvement, but this rate might be higher for people with anorexia. According to the National Association of Anorexia Nervosa and Associated disorders, 50-80% of the risk for both eating disorders is believed to be genetic.³ The link is strong enough that some researchers believe that a genetic predisposition is necessary to develop the disorder.

Brain Differences

In addition to the strong genetic link observed in people with anorexia, there also appear to be neurochemical abnormalities in people with the disorder. Specifically, some research indicates that people with anorexia have higher levels of serotonin and lower levels of dopamine than people without the condition. However, this finding doesn’t indicate that these neurochemical imbalances cause or increase the risk for anorexia, but they do appear to be related.

Environmental Factors & History of Trauma

A history of trauma or the experience of high levels of stress are also associated with higher risk for almost all mental health conditions, including eating disorders like anorexia. Research has found that having a dysfunctional family or home environment increased the risk for developing anorexia. Parenting style also appears to play a role, specifically parents who have high expectations or who place a high emphasis on external rewards.

Potential Risk Factors for Developing Anorexia

While having a genetic predisposition for anorexia or a history of trauma can significantly impact someone’s risk of developing the condition, there are other factors that can make it more likely as well. Risk factors for anorexia include being female, being a young adult, having a comorbid mental health condition, and having specific personality traits like high levels of perfectionism.

Risk factors for anorexia nervosa include:

• Being female: More women than men suffer from anorexia, and some research suggests that the societal pressure on females to be attractive and thin helps explain this gender discrepancy. Media exposure and peer influence do appear to play a role in increasing risk, further supporting this theory.
  • However, the gender gap is narrowing, with anorexia in men becoming more common. Males appear to be at higher risk for dying from the disorder, possibly because they are less likely to be diagnosed and treated early. Gay men are more likely to develop an eating disorder than straight men, as are individuals who identify as transgender.
• Being an adolescent or young adult: People are most at risk of developing anorexia during adolescence and young adulthood, which again may be partially due to the importance of peer acceptance during this stage in a person’s life. The average age of onset for anorexia is 15. The onset of puberty is generally considered a risk factor for onset of anorexia.
• Having specific personality traits: Certain personality traits are also thought to place some people at higher risk for developing anorexia. People who are prone to perfectionist tendencies are thought to be at higher risk, as are those who are competitive. People who are more risk-averse and prone to worrying and shyness are also thought to be at higher risk.
• Having OCD: There’s also a connection between OCD and eating disorders. People with certain obsessive-compulsive traits are believed to be at higher risk for anorexia. These traits include perfectionism, being rule-driven, a preference for order and symmetry, excessive doubt, and increased cautiousness. The study found that a person with all five traits was 35 times more likely to develop an eating disorder than someone with none of these traits.
• A history of dieting: Behaviors can also place certain people at risk for developing anorexia. Specifically, dieting is known to be a risk factor. As people experience success with weight loss and get positive attention from others, it can enforce restrictive eating patterns. Athletes might be at higher risk for developing anorexia and are sometimes encouraged by coaches and teammates to engage in restrictive or purging patterns to lose or maintain weight.
• Having a comorbid disorder: There are high rates of comorbidity with other mental health disorders in people with anorexia. While it is not clear that there is a causal relationship, it is estimated that 33-50% of people with anorexia also have a mood disorder like depression or bipolar disorder. Roughly half of people with anorexia have an anxiety disorder or a disorder where anxiety is a feature of the disorder (like obsessive compulsive disorder (OCD).

Effects of Anorexia

Anorexia has the highest mortality rate of any mental health condition, making it especially dangerous to live with without any treatment. Death often results from either medical complications like malnourishment or suicide.¹ Long-term effects of inadequate nutrition have horrible physical consequences for people with anorexia.

Long term effects of anorexia can include:¹

• Cold intolerance
• Yellowing skin
• Enamel erosion on teeth
• Growing lanugo (fine, downy hair on the arms)
• Hair loss
• Abdominal pain
• Fatigue
• Low blood pressure
• Slow heart rate
• Cardiovascular complications or heart damage
• Hypothermia
• Constipation
• Loss of period
• Low bone density
• Edema

When Should Someone With Anorexia Go to the Emergency Room?

Someone with anorexia should seek emergency care if they begin experiencing any change in heart rate, feeling faint or dizzy, chest pain, or trouble breathing. All body systems have a serious risk for complications when someone has anorexia nervosa.⁴ A slow and weak heart rate, called bradycardia, is a common development of someone with anorexia nervosa.⁴ Cardiac issues are one of the more common causes of sudden death in someone with anorexia nervosa.⁴

Additionally, anorexia nervosa often co-occurs with suicidal thoughts and attempts.⁴ If someone is experiencing any thoughts of harming themself or others, especially if they have a plan, visiting the emergency room to speak with a provider is a good idea.

How Is Anorexia Nervosa Diagnosed?

Anorexia nervosa can be diagnosed by a medical or mental health professional, but is often a team approach for diagnosis. Diagnosis typically consists of a diagnostic clinical interview, and commonly, medical exams and tests to assess the severity of the disorder. Since diagnosis requires the individual to be significantly underweight, a physical exam is often performed by a medical doctor to confirm severity of the disorder.

• Physical exam: A physical exam may be completed by a doctor to assess weight and other physical signs of anorexia, such as development of lanugo, loss of enamel, or bruising on the knuckles for purging-types of anorexia.
• Lab tests: Metabolic, vitamin, and electrolyte imbalances are common in people with anorexia. Lab tests can help a provider understand the extent of damage done by the disorder.
• Psychological evaluation: A mental health professional will conduct a psychological evaluation to assess the origin and maintenance of the disorder. They may ask you questions about when symptoms started, how often certain symptoms occur, and your thoughts about receiving treatment.
• X-rays: X-rays are an important piece of assessment because malnutrition can negatively impact bone density.
• Electrocardiograms: Since certain heart conditions can lead to heart failure when anorexia symptoms have progressed, an electrocardiogram can rule out any immediate issues that need attention.

During the diagnostic assessment, a clinician will specify the subtype of anorexia a person is suffering from (restricting type or binge-purge type). Clinicians diagnosing anorexia will also specify the severity of the disorder, which is determined on the client’s BMI. A BMI of 17 or higher is considered mild severity, a BMI between 16-16.99 is moderate, and a BMI of 15.99 or lower is considered severe.

Because of the high rate of mortality in patients with anorexia, understanding the severity of the disorder is important in determining risk and the most appropriate treatment. An eating disorder not otherwise specified (EDNOS) diagnosis may be given to individuals who meet some but not all of the criteria for an anorexia diagnosis.

Anorexia Nervosa Treatments

The treatment of anorexia typically involves an interdisciplinary team. This could include outpatient counseling, nutritional intervention, medication, intensive outpatient treatment or partial hospitalization, or residential/inpatient treatment. A combination of these treatments may be employed depending on the severity of the anorexia. Treatment of anorexia nervosa should always include a primary care physician to ensure the person suffering from anorexia is medically stable.

Hospitalization

Hospitalization for eating disorders is needed when the individual needs to restore weight and address medical complications that have happened as a result of their restriction.¹ Hospitalization offers a controlled environment where medical personnel can offer interventions like 24/7 monitoring, specialty visits, lab tests, and if needed, re-feeding. If a person is unable to eat and gain weight on their own, has an unstable heart rate, or has suicidal thoughts, hospitalization is required for recovery.

Residential Treatment

Residential treatment is generally where people go after hospitalization has resolved any acute medical issues. It involves temporarily living at an eating disorder treatment facility to restore weight and gain recovery skills. In residential treatment, people are likely to receive medical monitoring, individual and group therapy, and nutrition psychoeducation.

Nutrition Counseling

Nutrition counseling is an important piece of anorexia nervosa recovery. Nutrition counseling is generally offered during residential treatment, partial hospitalization, and outpatient programs. Through nutrition counseling, people with anorexia nervosa can learn how to adequately structure meals for proper nutrition. When someone steps down to outpatient therapy, they can add a registered dietician to their treatment to ensure they are continuing proper meal structuring and planning.

Psychotherapy

Therapy is an important piece of anorexia nervosa recovery because it addresses underlying emotional issues related to restriction and starvation. There are a variety of evidence-based approaches for therapy for eating disorders. Some approaches may address individual skills, although family therapies are also evidence-based treatments for anorexia nervosa which address relational dysfunctions that contribute to symptoms.

Therapy options for anorexia may include:

• Family-based therapy: Family-based therapy may be indicated when there are relational dysfunctions that maintain a person’s symptoms. Family-based therapies, such as the Maudsley Method, may also address how family members can be a part of someone’s recovery process, through support, or even preparing or eating meals together.⁵
• CBT-E: CBT-E is a newer version of cognitive behavioral therapy which has been adapted for use with eating disorders. It focuses on stabilizing eating, stopping compensatory behaviors, and challenging negative perceptions and cognitions that keep anorexia going.⁵
• ACT: ACT for anorexia nervosa encourages the commitment of living through core values, which often coincides with recovery values.⁵ Through ACT, the person learns skills to mindfully accept the things about recovery they cannot control, and live through their core values anyway.
• Cognitive remediation therapy: CRT is an approach which addresses issues with cognitive inflexibility found in anorexia.⁵ CRT has mixed results, but it may help individuals with anorexia learn to develop more flexible thinking patterns, leading to a reduction in symptoms.
• DBT: DBT for eating disorders encourages the development of four core life skills: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation.⁵ Through developing these skills, a person is better able to manage the distress that may trigger the urges for restriction.
• IPT: Interpersonal therapy focuses on helping the person with anorexia develop better social skills to maintain relationships. Through therapy, the person learns how relational distress is connected to their symptoms and to improve the state of important relationships.

Medication

There have been mixed results for using medication to treat eating disorders, including antidepressant and antipsychotic medications for people with anorexia nervosa.⁵ These drugs were initially thought to aid in treating underlying anxiety, depressive, or psychotic issues that contributed to symptoms.⁵ Studies have not necessarily replicated good results for resolving anorexia symptoms, however, clinicians continue to prescribe these medications, often due to the high rate of comorbid mood disorders.⁵ Olanzapine, a second-generation atypical antipsychotic, has also shown promise in promoting weight gain in individuals with anorexia, although alleviating psychological symptoms was mixed.⁵

Support Groups

Support groups can offer an addition to therapy for someone in recovery for anorexia nervosa. People with anorexia often experience relational distress, low self-esteem, and sometimes a lack of social skills that may maintain symptoms. Support groups led by clinicians also have the added benefit of having someone to provide basic psycho-education around recovery. For individuals who are receiving therapy such as DBT, support groups offer an opportunity to practice interpersonal skills taught in therapy.

How to Get Help for Anorexia

If you or someone you care about is suffering from anorexia, it is important to seek professional help. Speak with your primary care doctor to get a referral for a therapist or set up an appointment directly by using an online directory, or by contacting your health insurance provider. There are also online eating disorder recovery centers, like Equip Health, that offer help without having to leave your home.

It is important to find a therapist who specializes in eating disorders. Specifically, finding a Certified Eating Disorder Specialist (abbreviated as CEDS) is recommended. Specialists with this certification have gone through an extensive training and credentialing process with the International Association of Eating Disorders Professionals Foundation.

Coping With Anorexia

People who suspect they have anorexia should seek professional treatment as soon as possible. In addition to receiving professional help from a dietician, counselor, and doctor, people can take certain steps to live and cope with anorexia.

Beyond professional treatment, here are some other ways to live with anorexia and cope with related symptoms:

• Maintain a diverse and flexible diet and eating routine as opposed to one that is strict and regimented
• Adhere to the recommended daily calorie intake outlined by a licensed dietician or by the US Department of Health and Human Services’ dietary guidelines (2000 calories per day is a typical average)
• Be honest with doctors and other care providers about your food and exercise habits and any supplements you are taking
• Monitor and moderate stress and treat any co-occurring mental health conditions
• Limit use of social media/other forms of media exposure if you notice it’s impacting you
• Consider avoiding tracking calories, food intake, weight, or exercise unless you discuss it with professionals involved in your treatment
• Consult with a registered dietician, nutritionist, and other professionals involved in your treatment prior to engaging in diets or exercise routines aimed at weight loss
• Work on improving your body image and expose yourself to people, messages and media that promote body positivity
• Practice mindfulness or develop a meditation routine to work on distancing yourself from unhelpful thoughts that feed into your desire to binge, purge or restrict
• Listen to a variety of eating disorder podcasts to gain new perspectives and helpful tips

Helping Someone Else With Anorexia

Helping a loved one with an eating disorder like anorexia is a mix of maintaining your own personal boundaries while respecting your loved one’s boundaries around support. It can be difficult to watch a loved one struggle with restriction. Educating yourself, having your own support system, and communicating regularly with your loved one can help establish healthy boundaries while supporting their recovery process.

Here are some tips for helping a friend or loved one with anorexia nervosa:

• Get educated about the specifics of their disorder: Seek out accurate information on anorexia from health organizations, doctors, podcasts, and books. Understanding how your loved one’s diagnosis affects them is often the first step in beginning to empathize with symptoms.
• Talk to them with compassion about what you’re noticing: Develop a way to speak empathetically to your loved one about their concerning symptoms. Using I-statements and reflective listening can help you communicate how their behaviors affect you, while providing validation for their own emotional experiences.
• Get medical help: If needed, it is important to have a plan for how your loved one is willing to receive medical help. Medical help might vary from being an authorized contact for their therapist, taking them to doctor visits, or knowing when to seek care from emergency services.
• Offer practical support: Practical support in anorexia recovery often looks like helping with grocery shopping, meal preparation, and eating meals. Sometimes, however, practical support might be as simple as taking your loved one to doctor’s visits or offering to help with chores to lower their stress levels in recovery.
• Praise them for any positive changes you see: Offering verbal praise and validation can be an important piece of providing support and positive reinforcement for your loved one. Praising can be as simple as acknowledging efforts to finish a meal, not use compulsive exercise, or conquering a feared food.
• Help them build a support network: Support networks offer emotional validation throughout recovery. They can include friends, family, extended family, spiritual communities, or even online resources.
• Be their role model for healthy eating and exercise: Establishing good examples of what healthy eating and exercise look like can provide a visual for what life outside of anorexia will be for your loved one. It can give them a reason to keep pursuing recovery.

What Is the Outlook for Someone With Anorexia?

Recovering from anorexia is possible. Unfortunately, the longer someone has been ill generally means it may take longer to recover—and relapse rates are higher among these populations.⁵ Dedication to treatment, planning for obstacles, and following the treatment plan are strategies to maintain recovery.

Even after weight restoration has occurred, sometimes there are lifelong consequences that need management following anorexia. Some of these might include physical complications from the disorder, while other maintenance might include continued therapy and medications for psychological conditions.