Anorexia Nervosa

What is anorexia?

Anorexia (anorexia nervosa) is an eating disorder in which you restrict the number of calories you consume, resulting in a nutrient deficit and often — but not always — a very low body weight. People with anorexia also have an intense fear of gaining weight and a distorted body image. They often don’t recognize the seriousness of the condition.

If you think frequently about food and your weight, you’re not alone. This is very common — especially in today’s society. But obsessing over food and your weight can be a sign of a bigger problem. If you — or a loved one — develop a deep concern or fear of gaining weight, seek professional help as soon as possible. Anorexia is both a mental and physical condition. Without treatment, it can lead to malnutrition, serious health issues and even death.

Subtypes of anorexia

There are two subtypes of anorexia nervosa based on eating behaviors:

• Restrictive anorexia: With this subtype, the person severely limits the amount and type of food they consume.
• Binge-purge anorexia: With this subtype, the person greatly restricts the amount and type of food they consume. But they also have binge-eating and purging episodes. They may eat large amounts of food in a short time and then intentionally vomit or use laxatives or diuretics to get rid of what they consumed.

How common is anorexia?

Anorexia nervosa affects 0.3% to 1% of people in the United States. It more commonly affects people assigned female at birth (AFAB). But it can develop in people of any age, gender, race, ethnicity, sexual orientation and economic status.

What are the signs and symptoms of anorexia?

Anorexia involves physical, behavioral and mental signs and symptoms.

You can’t tell if a person has anorexia just by their appearance. You don’t need to have underweight (BMI under 18.5) to have anorexia — people without underweight can also have anorexia. This is called atypical anorexia. In addition, someone can have underweight without having anorexia.

Mental and emotional signs of anorexia

Emotional and mental signs of anorexia include:

• Intense fear of gaining weight.
• Inability to realistically assess your body weight and shape (having a distorted self-image).
• Obsessive interest in food, calories and dieting.
• Fear of certain foods or food groups.
• Being very self-critical.
• Denying the seriousness of your low body weight and/or food restriction.
• Feeling a strong need to be in control.

It’s common to have other mental health conditions alongside anorexia, so you may have additional mental and emotional symptoms.

Behavioral signs of anorexia

Behavioral signs of anorexia include:

• Changes in eating habits or routines, like eating foods in a certain order or rearranging foods on a plate.
• A sudden change in food preferences, like eliminating certain food types or food groups.
• Making frequent comments about feeling “fat” or having overweight despite weight loss.
• Purging through intentional vomiting and/or misusing laxatives or diuretics.
• Going to the bathroom right after eating.
• Misusing diet pills or appetite suppressants.
• Compulsive and/or excessive exercising.
• Continuing to limit calories even when your weight is low for your sex, height and age.
• Wearing loose clothing and/or wearing layers to hide weight loss and stay warm.
• Withdrawing from loved ones and social events.

Physical signs and symptoms of anorexia

Physical signs of anorexia may include:

• Significant weight loss over several weeks or months.
• Not maintaining an appropriate body weight based on your height, age, sex, stature and physical health.
• Unexplained change in growth curve or body mass index (BMI) in children and still-growing adolescents.

Physical signs and symptoms of anorexia that are side effects of starvation and malnutrition include:

• Dizziness and/or fainting.
• Fatigue.
• Abnormal heart rhythm (arrhythmia).
• Low blood pressure (hypotension).
• Feeling cold all the time.
• Absent periods (amenorrhea) or irregular menstrual periods.
• Bloating and/or abdominal pain.
• Muscle weakness and loss of muscle mass.
• Dry skin, brittle nails and/or thinning hair.
• Poor wound healing and frequent illness.

What causes anorexia?

Anorexia is a complex condition. There’s no single cause. Research suggests that a combination of certain factors might be responsible, like:

• Genetics: Research suggests that approximately 50% to 80% of the risk of developing an eating disorder is genetic. People with first-degree relatives (biological siblings or parents) with an eating disorder are 10 times more likely to develop one.
• Brain changes: Changes in brain chemistry may play a role, particularly changes to your brain’s reward system and balance of neurotransmitters (chemical messengers). Neurotransmitters like serotonin and dopamine can affect appetite, mood and impulse regulation.
• Trauma: Many experts believe that eating disorders happen when someone attempts to cope with overwhelming feelings and painful emotions by having intense control over something else. In the case of anorexia, it’s controlling how much food you consume. Physical abuse or sexual assault, for example, can contribute to some people developing an eating disorder.
• Environment and culture: Cultures that idealize a particular body type — usually “thin” bodies — can place unnecessary pressure on people to achieve unrealistic body standards. Popular culture, social media and advertising images often link thinness to popularity, success, beauty and happiness.
• Peer pressure: Particularly for children and adolescents, peer pressure can be a very powerful force. Experiencing teasing or bullying because of appearance or weight can contribute to the development of anorexia.
• Emotional health: Perfectionism, impulsive behavior and difficult relationships can all play a role in lowering your self-esteem and perceived self-worth. This can make you vulnerable to developing anorexia.

It’s important to note that there’s no single path to an eating disorder or anorexia. For many people, irregular eating behaviors (also called disordered eating) make up an inappropriate coping strategy that becomes permanent over time. This disordered eating pathway is true for some, but not all, who develop anorexia.

How is anorexia diagnosed?

A healthcare provider can diagnose anorexia nervosa based on the criteria for it listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The three criteria include:

• Restriction of calorie consumption that leads to weight loss or a failure to gain weight. This results in a significantly low body weight based on your age, sex, height and stage of growth.
• Intense fear of gaining weight or becoming “fat.”
• Having a distorted view of yourself and the seriousness of the state of your health.

The DSM-5 criteria classify the severity of anorexia according to body mass index (BMI). People who meet the criteria for anorexia but don’t have underweight despite significant weight loss have atypical anorexia.

If you have signs and symptoms of anorexia, a provider will do a complete medical history and physical exam. The provider will likely ask questions about your:

• Dietary history.
• Exercise history.
• Psychological history.
• Body image.
• Purging frequency and elimination habits (use of diet pills, laxatives and diuretics).
• Family history of eating disorders.

A person with anorexia or any eating disorder will have the best recovery outcome if they receive an early diagnosis. If you or someone you know is experiencing signs and symptoms of anorexia, be sure to talk to a provider as soon as possible.

Tests that assess anorexia nervosa

Laboratory tests alone can’t diagnose anorexia. But your healthcare provider may use various tests to rule out any medical conditions that could cause weight loss. Tests can also evaluate the physical effects of anorexia.

These tests may include:

• Complete blood count (CBC) to assess overall health.
• Electrolyte panel to check for dehydration and your blood’s acid-base balance.
• Electrocardiogram (EKG) to check heart health.
• Urinalysis to check for a wide range of conditions.
• Bone density test to check for weak bones (osteoporosis).
• Kidney function tests.
• Liver function tests.
• Thyroid blood tests.

What is the treatment for anorexia?

The biggest challenge in treating anorexia is helping the person recognize and accept that they have a serious condition. Many people with anorexia deny they have an eating disorder. They often seek medical treatment only when their condition is life-threatening. This is why it’s important to diagnose and treat anorexia in its beginning stages.

The goals of anorexia treatment include:

• Stabilizing weight loss.
• Beginning nutrition rehabilitation to restore weight.
• Eliminating binge eating and/or purging behaviors and other problematic eating patterns.
• Treating psychological concerns, like low self-esteem and distorted thinking patterns.
• Developing long-term behavioral changes.

People with eating disorders, including anorexia, often have additional mental health conditions, like:

• Depression or other mood disorders.
• Anxiety.
• Post-traumatic stress disorder (PTSD).
• Borderline personality disorder.
• Obsessive-compulsive disorder.
• Substance use disorders.

These conditions can further complicate anorexia. If you have one or more of these conditions, your healthcare team will recommend treatment for them, as well.

Treatment options will vary depending on your needs. You may receive treatment through residential care (inpatient hospitalization) or outpatient care based on your current medical and mental health state. Treatment for anorexia most often involves a combination of:

• Individual and group psychotherapy (talk therapy).
• Medication.
• Hospitalization.

Psychotherapy for anorexia

Psychotherapy (talk therapy) is a type of individual counseling that focuses on changing your thinking and behavioral patterns. Treatment includes practical techniques for developing healthy attitudes toward food and weight. It also involves approaches for changing how you respond to difficult situations. There are several types of psychotherapy, including:

• Acceptance and commitment therapy: The goal is to develop motivation to change actions rather than your thoughts and feelings.
• Cognitive behavioral therapy (CBT): The goal of CBT is to address distorted views and attitudes about weight, shape and appearance and to practice behavioral changes.
• Cognitive remediation therapy: This therapy uses reflection and guided supervision to develop the capability of focusing on more than one thing at a time.
• Dialectical behavior therapy (DBT): Specific skills you’ll learn in DBT include building mindfulness, improving relationships, managing emotions and tolerating distress.
• Interpersonal psychotherapy (IPT): IPT involves improving relationships and communication, which may reduce eating disorder symptoms.
• Psychodynamic psychotherapy: This therapy involves looking at the root causes of anorexia as the key to recovery.

Group and/or family therapy

Family support is very important to anorexia treatment success. Family members must understand the eating disorder and recognize its signs and symptoms.

Family-based therapy for anorexia — also called the Maudsley Method — involves family-based refeeding. This means putting the caregivers and family in charge of helping the person with anorexia get the appropriate amount of nutrition. Studies show that it’s the most effective method to restore health to a person with anorexia under the age of 18.

People with eating disorders might also benefit from group therapy, where they can find support and openly discuss their feelings and concerns with others who share common experiences.

Medication

Some healthcare providers may prescribe medication to help manage anxiety and depression, which often exist alongside anorexia. The antipsychotic medication olanzapine (Zyprexa^®) may be helpful for weight gain. Sometimes, providers prescribe medications to help with menstrual period regulation.

Hospitalization for anorexia

Hospitalization might be necessary to treat severe weight loss that has resulted in malnutrition and other serious mental or physical health complications. These include heart disorders, severe depression, and suicidal thoughts or behaviors.

What are the possible complications of anorexia treatment?

The most serious complication of treating anorexia is a condition called refeeding syndrome. It can happen when a seriously malnourished person begins to receive nutrition again. Basically, their body can’t properly restart the process of using food for energy (metabolism).

Since refeeding syndrome can have serious and life-threatening side effects, people with anorexia need to receive medical treatment and/or guidance.

How long does it take to recover from anorexia?

Every person’s anorexia recovery journey is different. The important thing to remember is that it’s possible to recover from anorexia. Treatment often involves many components. And each of these components can take different amounts of time.

No matter where you or a loved one is in their journey, it’s essential to continue working toward recovery.

Is anorexia preventable?

It’s not always possible to prevent anorexia. But it’s helpful to start treatment as soon as you develop signs of it.

In addition, encouraging healthy eating habits and realistic attitudes about food and body image during childhood might help prevent the development or worsening of eating disorders.

What is the prognosis for someone with anorexia?

The prognosis (outlook) for someone with anorexia varies depending on certain factors, like:

• How long they’ve had anorexia.
• The severity of the condition.
• The type of treatment and adherence to treatment.

Anorexia gets worse the longer it goes untreated. People with anorexia often won’t admit they have a problem and might resist treatment or refuse to follow the treatment plan.

Without treatment, anorexia is potentially life-threatening. Eating disorders, including anorexia, are among the deadliest mental health conditions. People with anorexia are five times more likely to die prematurely and 18 times more likely to die by suicide.

The good news is that anorexia can be treated, and someone with anorexia can return to a healthy weight and healthy eating patterns. Unfortunately, the risk of relapse is high, so recovery from anorexia usually requires long-term treatment. Support of family members and friends can help ensure that the person receives — and sticks to — their needed treatment.

What are the complications of anorexia?

Malnutrition and starvation can affect nearly every organ in your body. Severe organ damage may be irreversible even after you’ve recovered from anorexia.

Complications that can result from untreated anorexia include:

• Loss of bone mass (osteoporosis) and tooth enamel erosion.
• Kidney and liver damage.
• Fatty liver disease (steatosis).
• Rhabdomyolysis (rapid breakdown of skeletal muscle).
• Delayed puberty and physical growth.
• Infertility and menstrual problems.
• Insomnia.
• Anemia.
• Peripheral neuropathy.
• Ventricular arrhythmia.
• Mitral valve prolapse.
• Cardiac arrest.
• Death.

In addition to physical complications, people with anorexia often have other mental health conditions. Without treatment, these conditions could lead to self-harm, suicidal thoughts or suicide attempts. If you’re having suicidal thoughts, call the Suicide and Crisis Lifeline at 988. Someone will be available to talk with you 24/7.

A note from Cleveland Clinic

It’s common to have feelings of shame, embarrassment and/or fear when it comes to eating disorders. Know that it’s OK to ask for help. Seeking care for anorexia and other mental health conditions is no different from seeking medical care for a physical condition. It may not feel like it now, but it’s possible for you to feel better both mentally and physically.

If you’re concerned a loved one has anorexia, you may not know how to confront them or get them help. Lean on medical professionals for guidance. They can provide you with resources and strategies for effectively — and empathetically — talking to your loved one. The sooner your loved one can get a diagnosis and treatment, the better.