Anorexia is a life-threatening mental health condition characterized by disordered eating patterns and a fear of weight gain. People with anorexia are often significantly underweight and 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.
What Is 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.
2 Types of Anorexia Nervosa
There are two subtypes that are used to distinguish between different eating patterns noted in people with the disorder. These types are restricting and binge-eating/purging.
The two subtypes of anorexia are:
1. Restricting Type
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 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 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
2. 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: people 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
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: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)
Signs of Anorexia Nervosa
Anorexia manifests as changes in a person’s eating behavior as well as other physical and emotional indicators.
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)
- 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)
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
- Increased self-criticism
- Low self-esteem
- Lowered stress tolerance
Anorexia Vs. Bulimia Vs. Other Specified Feeding or Eating Disorder
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 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.” 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.
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Causes & 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.
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.
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.9 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 doesn’t indicate that these neurochemical imbalances cause or increase the risk for anorexia, but they do appear to be related.
Who Does Anorexia Effect?
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 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 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.
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.
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.
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.
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. 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).
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.
What to Expect at Your First Appointment
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.
Diagnosis of Anorexia
During the diagnostic assessment, a clinician will specify the subtype of anorexia a person is suffering from (i.e., restricting the type of 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, determining the severity of the disorder is important in determining risk and the most appropriate treatment.
Anorexia Quizzes, Tests, & 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.
Treatment of Anorexia Nervosa
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.
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, people can take certain steps to live and cope with anorexia.
Steps to live and cope with anorexia are:
- 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
Here are relevant anorexia statistics:
- 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
Final Thoughts on Anorexia Nervosa
Building and maintaining a healthy relationship with food and a healthy body image requires continuous effort. Even people who have been in recovery from anorexia for years need to remain vigilant for signs of relapse, especially during times of stress.