Anorexia is a life-threatening mental health condition characterized by a fear of weight gain and disordered eating patterns. People with anorexia are often significantly underweight but have a distorted view of their bodies. This leads them to restrict their food intake or engage in other behaviors to attempt to lose weight.
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 or 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.
Building and maintaining a healthy relationship with food requires ongoing effort, and people who have struggled with anorexia must remain vigilant to avoid relapse, especially during times of stress.
Types of Anorexia Nervosa
Anorexia is a type of eating disorder characterized by restrictive eating patterns. Not all people with anorexia display the same disordered eating patterns. There are two subtypes that are used to distinguish between different eating patterns noted in people with the disorder.
The two subtypes of anorexia are:
People with the restricting type of anorexia display restrictive patterns of eating. They may refuse to eat certain types or categories of food (like meat or food high in fat) 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 include:
- Fasting/food restriction: People may fast or greatly restrict their eating following a binge. They may follow a strict diet where they only eat certain low-calorie foods or avoid certain types or groups of food.
- Compulsive exercise: People may engage in compulsive exercise patterns following a binge. 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.
People with the binge-eating/purging type of anorexia display behaviors typically associated with bulimia nervosa, another eating disorder. This subtype differs from the restricting subtype because there is a pattern of binge eating. Binge eating is when people eat large amounts of food in a short amount of time, resulting in feeling overly full, uncomfortable, and typically guilty. To achieve weight loss or prevent weight gain, they may purge by vomiting, laxative or diuretic use. 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: People may consume laxatives (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.
Signs of Anorexia Nervosa
Anorexia manifests as changes in a person’s eating behavior as well as other physical and emotional indicators.
Some of the early behavioral indicators of anorexia can 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
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). Having a low body weight is still a symptom of anorexia, but intense weight loss with resulting normal BMI can cause significant medical problems.
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)
- Pale dry skin
- Brittle nails
- Hand calluses
- Growth of excessive body hair
- Increased sensitivity to cold temperatures
- Loss of sexual drive and interest
- Gum disease, stained teeth, and tooth decay (particularly in the binge-purge subtype)
People with anorexia sometimes also develop changes in their mood and mental health. Warning signs include:
- Withdrawal from friends or family
- Rigid routines and the need for things being a certain way
- Sadness or depression
- Increased anxiety
- Increased self-criticism
- Low self-esteem
- Lowered stress tolerance
Symptoms of Anorexia Nervosa
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 include:
- 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)
A clinician will also specify during the diagnostic assessment which subtype of anorexia a person is suffering from, either:
- Restricting type: when types or quantities of food are restricted or eliminated
- Binge-purge type: when they report episodes of binge eating in addition to restricting or purging behaviors
Anorexia (the binge-eating/purging subtype) and bulimia are two eating disorders that share similar symptoms. The main distinguishing factor between the two disorders is that anorexia features low body weight while bulimia does not specify weight as a symptom. A person can be diagnosed with Anorexia despite having a normal weight if they have lost a significant amount of weight in a short time and have concerning medical symptoms.
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, determining the severity of the disorder is important in determining risk and the most appropriate treatment.
Causes and Triggers of Anorexia Nervosa
Like all mental health disorders, there is no singular cause for anorexia. A complex combination of biological and social/environmental factors are thought to place some people at higher risk than others for developing the disorder.
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. The gender gap is narrowing, and more men are being diagnosed with anorexia. 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 transgendered.
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.
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.
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 bulimia and anorexia is believed to be genetic. The link is strong enough that some researchers believe that a genetic predisposition is necessary to develop the disorder.
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 people with anorexia have higher levels of serotonin and lower levels of dopamine than people without the condition. However, this finding does not indicate that these neurochemical imbalances cause or increase the risk for anorexia, but they do appear to be related.
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 at 33-50% of people with anorexia also have a mood disorder like depression or bipolar. Roughly half of people with anorexia have an anxiety disorder or a disorder where anxiety is a feature of the disorder (like OCD).
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. People with certain obsessive-compulsive traits are also 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 thirty five times more likely to develop an eating disorder than someone with none of these traits.
Finally, behaviors can also place certain people at risk for developing anorexia. Specifically, dieting is known to be a significant risk factor. As people experience success with weight loss and get positive attention from others, it can reinforce restrictive eating patterns. Athletes might also 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.
- 30 million Americans suffer from an eating disorder
- 95% of people with anorexia are between the ages of 12-25
- 10% of people with anorexia die from the disease, making it the most fatal mental illness
- Suicide is the cause of 1 out of 5 deaths in people with anorexia
- 50-80% of the risk for anorexia is genetic
- As many as 50% of people with anorexia have a mood disorder, anxiety disorder or OCD
- 80-90% of people with anorexia are female
- In a study of adolescents, moderate dieters were 5x more likely to develop an eating disorder, and extreme dieters were 18x more likely to develop an eating disorder
- 42% of men who have an eating disorder identify as gay
Anorexia Quizzes, Tests and Self Diagnosis
Only a licensed health or mental health professional can diagnose anorexia. This typically occurs in a structured assessment with a doctor or licensed counselor. It is recommended that you schedule an appointment to speak with a doctor or licensed therapist to verify a diagnosis if you have any of the listed symptoms of anorexia or if you are concerned about your weight or eating patterns.
Anorexia vs Bulimia vs Other Specified Feeding or Eating Disorder
The two eating disorders most commonly confused are anorexia nervosa and bulimia nervosa. Alternating between episodes of binge eating and restricting/purging is a pattern noted in both bulimia and the binge/purge subtype of anorexia.
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 a healthy weight, or even overweight, they are more likely to be diagnosed with bulimia. Differentiating between bulimia and anorexia 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 do not meet full criteria for anorexia or bulimia and are diagnosed with an “Other Specified Feeding or Eating Disorder.” 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. For instance, a person might receive this diagnosis if they restrict food intake but are not underweight or if their binging/purging behavior is infrequent.
How to Get Help for Anorexia
If you or someone you care about is suffering from anorexia or suspect you may have an eating disorder, 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 insurance provider.
During the first appointment, the therapist will assess your symptoms and talk with you about options for treatment. It is important to find a therapist who specializes in eating disorders. Specifically, finding a Certified Eating Disorder Specialist (abbreviated as CEDS) is recommended. Individuals with this certification have gone through an extensive training and credentialing process with the International Association of Eating Disorders Professionals Foundation. Depending on your current symptoms and needs, the therapist will make recommendations for further treatment.
Treatment of Anorexia Nervosa
Fortunately, there are effective treatment options for people who have anorexia. Treatment options range from weekly outpatient therapy sessions to more intensive inpatient care. The more severe a person’s symptoms are, the more intensive care they require. Typically, treatment needs are determined through a collaborative discussion between a health or mental health professional and the patient.
Anorexia is a serious psychiatric disorder and has the highest mortality rate of any other mental health disorder. People with anorexia are also at risk for numerous health problems including heart failure, kidney or liver failure, and bone density loss. A primary care physician is needed to monitor and evaluate the patient regularly and recommend hospitalization in order to stabilize the patient if needed.
Outpatient counseling is usually provided in an office setting by a licensed counselor, social worker, or psychologist. Sessions generally are offered 1-2 times per week and typically last about an hour. Depending on the age of the client, their life circumstances, and their personal preference, treatment could include individual sessions or sessions that include family members or other support people. In some cases, group therapy is offered in addition to or instead of individual or family sessions. Therapists may use different techniques and styles of therapy. The therapies that currently have the most research support with eating disorders are Cognitive Behavioral Therapy (CBT) and Family-based treatments.
In many cases, people with anorexia are recommended to see a nutritionist or dietician in addition to psychotherapy or other forms of treatment. Nutritional guidance should be provided by a Registered Dietician (RD) who is well-versed in the treatment of eating disorders. The particular recommendations the RD makes will vary depending on an assessment of the client’s current weight, health, and nutritional needs. The involvement of an RD is often essential in monitoring weight restoration and food intake throughout the recovery process.
In some instances, a person with anorexia benefits from consulting with a prescribing professional (i.e. a doctor, nurse practitioner or psychiatrist). The purpose of medication may be to address underlying health issues related to or caused by the eating disorder. Anemia and vitamin deficiencies are common issues in patients with anorexia.
While antidepressants and antipsychotic medications are not prescribed to treat anorexia, they are frequently prescribed to treat other psychiatric illnesses or symptoms that frequently co-occur with anorexia. For example antidepressants to treat depression and anxiety or antipsychotics to address obsessive compulsive behaviors that can present in anorexia.
Intensive Outpatient and Partial Hospitalization
Intensive outpatient and partial hospitalization programs that specialize in eating disorders are sometimes recommended for individuals with anorexia who have more severe symptoms or who are stepping down from inpatient or residential care. These are structured day programs offered several days a week that involve group or individual therapy and other treatment-related activities led by mental health professionals.
Often, intensive outpatient and partial hospitalization programs employ an interdisciplinary team that includes Registered Dieticians, counselors, and doctors or prescribing professionals. This interdisciplinary team allows these programs to provide more comprehensive wrap-around services to those recovering from eating disorders.
Residential or Inpatient Treatment
In some instances, more intensive treatment for anorexia is needed. In these cases, people may be referred to a residential or inpatient setting where they are provided with 24 hour monitoring in a structured environment. Residential programs tend to be less restrictive than other inpatient settings that operate more like hospitals, and they typically offer structured programming that includes nutritional support, group and individual counseling, and some medical monitoring.
Other inpatient treatment facilities provide more intensive medical monitoring and are recommended for patients with severe anorexia who require more comprehensive medical or psychological treatment.
Living and Coping with Anorexia
People who suspect they have anorexia are urged to seek professional treatment. In addition to receiving professional help from a dietician, counselor and doctor, some additional steps people with anorexia can take to prevent relapse include:
- 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
People who have been in recovery from anorexia for years need to remain vigilant for signs of relapse, especially during times of stress. Building and maintaining a healthy relationship with food and a healthy body image requires continuous effort. Many people in recovery from anorexia and other eating disorders find that there are certain situations or foods that trigger urges to binge, purge, or restrict. They need to remain aware of these triggers and subtle signs that they are becoming overly focused on food, weight, or the appearance of their body.