Anorexia Nervosa

Overview

What is anorexia nervosa?

Anorexia, formally known as anorexia nervosa, is an eating disorder. People with anorexia limit the number of calories and the types of food they eat. Eventually, they lose weight or cannot maintain an appropriate body weight based on their height, age, stature and physical health. They may exercise compulsively and/or purge the food they eat through intentional vomiting and/or misuse of laxatives.

Individuals with anorexia also have a distorted self-image of their body and have an intense fear of gaining weight.

Anorexia is a serious condition that requires treatment. Extreme weight loss in people with anorexia can lead to malnutrition, dangerous health problems and even death.

Who does anorexia affect?

Anorexia can occur in people of any age, sex, gender, race, gender, ethnicity, sexual orientation and economic status and individuals of all body weights, shapes and sizes. Anorexia most commonly affects adolescents and young adult women, although it also occurs in men and is increasing in numbers in children and older adults.

How common is anorexia?

Eating disorders affect at least 9% of the worldwide population, and anorexia affects approximately 1% to 2% of the population. It affects 0.3% of adolescents.

What is the difference between anorexia and bulimia?

Anorexia nervosa and bulimia nervosa are both eating disorders. They can have similar symptoms, such as distorted body image and an intense fear of gaining weight. The difference is that they have different food-related behaviors.

People who have anorexia severely reduce their calorie intake and/or purge to lose weight. People who have bulimia eat an excessive amount of food in a short period of time (binge eating) followed by certain behaviors to prevent weight gain. Such behaviors include:

  • Intentional (self-induced) vomiting.
  • Misuse of medications such as laxatives or thyroid hormones.
  • Fasting or exercising excessively.

People with bulimia usually maintain their weight at optimal or slightly above optimal levels whereas people with anorexia typically have a body mass index (BMI) that is below 18.45 kg/m2 (kilogram per square meter).

Symptoms and Causes

What are the signs and symptoms of anorexia?

You cannot tell if a person has anorexia just by their appearance because anorexia also involves mental and behavioral components — not just physical. A person does not need to be underweight to have anorexia. Larger-bodied individuals can also have anorexia. However, they may be less likely to be diagnosed due to cultural stigma against fat and obesity. In addition, someone can be underweight without having anorexia. Remember, anorexia also includes psychological and behavioral components as well as physical.

There are several emotional, behavioral and physical signs and symptoms of anorexia. If you or someone you know experiences the signs and symptoms of anorexia below, it’s important to seek help.

Emotional and mental signs of anorexia

Emotional and mental signs of anorexia include:

  • Having an intense fear of gaining weight.
  • Being unable to realistically assess your body weight and shape (having a distorted self-image).
  • Having an obsessive interest in food, calories and dieting.
  • Feeling overweight or “fat,” even if you’re underweight.
  • 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 desire to be in control.
  • Feeling irritable and/or depressed.
  • Experiencing thoughts of self-harm or suicide.

Behavioral signs of anorexia

Behavioral signs of anorexia include:

  • Changes in eating habits or routines, such as eating foods in a certain order or rearranging foods on a plate.
  • A sudden change in dietary preferences, such as eliminating certain food types or food groups.
  • Making frequent comments about feeling “fat” or overweight despite weight loss.
  • Purging through intentional vomiting and/or misusing laxatives or diuretics
  • Going to the bathroom right after eating.
  • Using diet pills or appetite suppressants.
  • Compulsive and excessive exercising or extreme physical training.
  • Continuing to diet even when your weight is low for your sex, height and stature.
  • Making meals for others but not yourself.
  • Wearing loose clothing and/or wearing layers to hide weight loss and stay warm.
  • Withdrawing from friends and social events.

Physical signs and symptoms of anorexia

The most well-known physical sign of anorexia is low body weight for a person’s height, sex and stature. However, it’s important to remember that someone can have anorexia without being underweight. In addition to weight-related signs of anorexia, there are also physical symptoms that are actually side effects of starvation and malnutrition.

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

What causes anorexia?

Anorexia and all eating disorders are complex conditions. For this reason, the exact cause of anorexia is unknown, but research suggests that a combination of certain genetic factors, psychological traits and environmental factors, especially sociocultural factors, might be responsible.

Factors that may be involved in developing anorexia include:

  • Genetics: Research suggests that approximately 50% to 80% of the risk of developing an eating disorder is genetic. People with first-degree relatives (siblings or parents) with an eating disorder are 10 times more likely to develop an eating disorder, which suggests a genetic link. Changes in brain chemistry may also play a role, particularly changes to the brain reward system and neurotransmitters, such as serotonin and dopamine, which can affect appetite, mood and impulse control.
  • Trauma: Many experts believe that eating disorders, including anorexia, are caused by people attempting to cope with overwhelming feelings and painful emotions by controlling food. 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 and images in media and advertising often link thinness to popularity, success, beauty and happiness. This may contribute to someone developing anorexia.
  • Peer pressure: Particularly for children and adolescents, peer pressure can be a very powerful force. Experiencing teasing, bullying or ridiculing 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 a person’s self-esteem and perceived self-worth. This can make them 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”) represent an inappropriate coping strategy that becomes permanent over time. This pathway to disordered eating is true for some, but not all, who develop anorexia.

Diagnosis and Tests

How is anorexia diagnosed?

A healthcare provider can diagnose a person with anorexia based on the criteria for anorexia nervosa listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association. The three criteria for anorexia nervosa under the DSM-5 include:

  • Restriction of calorie consumption leading to weight loss or a failure to gain weight resulting in a significantly low body weight based on that person’s age, sex, height and stage of growth.
  • Intense fear of gaining weight or becoming “fat.”
  • Having a distorted view of themselves and their condition. In other words, the individual is unable to realistically assess their body weight and shape believes their appearance has a strong influence on their self-worth and denies the medical seriousness of their current low body weight and/or food restriction.

Even if all of the DSM-5 criteria for anorexia aren’t met, a person can still have a serious eating disorder. DSM-5 criteria classifies the severity of anorexia according to body mass index (BMI). Individuals who meet the criteria for anorexia but who aren’t underweight despite significant weight loss have what’s known as atypical anorexia.

Diagnostic guidelines in the DSM-5 also allow healthcare providers to determine if a person is in partial remission (recovery) or full remission as well as to specify the current severity of the condition based on body mass index (BMI).

If signs and symptoms of anorexia are present, a healthcare provider will begin an evaluation by performing a complete medical history and physical examination. The provider or a mental health professional will likely ask questions about the following topics:

  • Dietary history (attitudes about food, dietary restriction).
  • Exercise history.
  • Psychological history.
  • Body image (this includes behaviors such as how often you weigh yourself).
  • Bingeing and purging frequency and elimination habits (use of diet pills, laxatives and supplements).
  • Family history of eating disorders.
  • Menstrual status (if your periods are regular or irregular).
  • Medication history.
  • Prior treatment.

It’s important to remember that 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 healthcare provider as soon as possible.

What tests are used to diagnose or assess anorexia?

Although there are no laboratory tests to specifically diagnose anorexia, a healthcare provider may use various diagnostic tests, such as blood tests, to rule out any medical conditions that could cause weight loss and to evaluate the physical damage weight loss and starvation may have caused.

Tests to rule out weight-loss causing illness or to assess anorexia side effects may include:

  • Complete blood count to assess overall health.
  • An electrolyte blood panel to check for dehydration and your blood’s acid-base balance.
  • Albumin blood test to check for liver health and nutrient deficiency.
  • 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 function tests.
  • Vitamin D levels.
  • A pregnancy test in people assigned female at birth who are of childbearing age.
  • Hormone tests if evidence of menstrual problems in people assigned female at birth (to rule out other causes) and measuring testosterone in people assigned male at birth.

Management and Treatment

How is anorexia treated?

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

The goals of treatment for anorexia include:

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

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

These conditions can further complicate anorexia, so if an individual has one or more of these conditions, their healthcare team will likely recommend treatment for the condition(s) as well.

Treatment options will vary depending on the individual’s needs. A person may receive treatment through residential care (outpatient care) or hospitalization depending on their current medical and mental health state. Treatment for anorexia most often involves a combination of the following strategies:

  • Psychotherapy.
  • Medication.
  • Nutrition counseling.
  • Group and/or family therapy.
  • Hospitalization.

Psychotherapy

Psychotherapy is a type of individual counseling that focuses on changing the thinking (cognitive therapy) and behavior (behavioral therapy) of a person with an eating disorder. Treatment includes practical techniques for developing healthy attitudes toward food and weight, as well as approaches for changing the way the person responds to difficult situations. There are several types of psychotherapy, including:

  • Acceptance and commitment therapy: This therapy’s goal is to develop motivation to change actions rather than your thoughts and feelings.
  • Cognitive behavioral therapy (CBT): This therapy’s goal is to address distorted views and attitudes about weight, shape and appearance and to practice behavioral modification (if “X” happens, I can do “Y” instead of “Z”).
  • 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): This therapy helps you not just develop new skills to handle negative triggers but also helps you develop insight to recognize triggers or situations where a non-useful behavior might occur. Specific skills include building mindfulness, improving relationships through interpersonal effectiveness, managing emotions and tolerating stress.
  • Family-based therapy (also called the Maudsley Method): This therapy involves family-based refeeding, which means putting the parents and family in charge of getting the appropriate nutritional intake consumed by the person with anorexia. It’s the most evidence-based method to physiologically restore health to an individual with anorexia who is under 18 years of age.
  • Interpersonal psychotherapy: This therapy is aimed at resolving an interpersonal problem area. Improving relationships and communications and resolving identified problems may reduce eating disorder symptoms.
  • Psychodynamic psychotherapy: This therapy involves looking at the root causes of anorexia as the key to recovery.

Medication

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

Nutrition counseling

Nutrition counseling is a strategy to help treat anorexia that involves the following:

  • Teaching a healthy approach to food and weight.
  • Helping restore normal eating patterns.
  • Teaching the importance of nutrition and a balanced diet.
  • Restoring a healthy relationship with food and eating.

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.

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.

Hospitalization

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

The most serious complication of treating anorexia is a condition called refeeding syndrome. This life-threatening condition can occur when a seriously malnourished person begins to receive nutrition again. Basically, their body cannot properly restart the metabolism process.

People experiencing refeeding syndrome can develop the following conditions:

  • Whole-body swelling (edema).
  • Heart failure and/or lung failure.
  • Gastrointestinal problems.
  • Extensive muscle weakness.
  • Delirium.
  • Death.

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

People who have one or more of the following risk factors for developing refeeding syndrome may need to be treated in a hospital:

  • Are severely malnourished (less than 70% median BMI in adolescents; a BMI of less than 15 in adults).
  • Have had little or no calorie intake for more than 10 days.
  • Have a history of refeeding syndrome.
  • Have lost a lot of weight in a very short period of time (10% to 15% of total body mass within three to six months).
  • Drink significant amounts of alcohol.
  • Have a history of misusing laxatives, diet pills, diuretics, or insulin (if they have diabetes).
  • Have abnormal electrolyte levels before starting refeeding.

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 is possible to recover from anorexia. Treatment for anorexia often involves many components, such as psychological therapy, nutritional counseling and addressing the cause of the person’s anorexia, if possible, and each of these components can take different amounts of time.

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

Prevention

What are the risk factors for developing anorexia?

Anorexia can affect anyone, no matter their gender, age or race. However, certain factors put some people at greater risk for developing anorexia, including:

  • Age: Eating disorders, including anorexia, are more common in adolescents and young adults, but young children and older adults can still develop anorexia.
  • Gender: Women and girls are more likely to be diagnosed with anorexia. However, it’s important to know that men and boys can have anorexia and may be under-diagnosed due to differences in seeking treatment.
  • Family history: Having a parent or sibling (first-degree relative) with an eating disorder increases your risk of developing an eating disorder, such as anorexia.
  • Dieting: Dieting taken too far can develop into anorexia.
  • Changes and trauma: Big changes in your life, such as going to college, starting a new job or going through a divorce, and/or trauma, such as sexual assault or physical abuse, may trigger the development of anorexia.
  • Certain careers and sports: Eating disorders are especially common amongst models, gymnasts, runners, wrestlers and dancers.

Can anorexia be prevented?

Although it might not be possible to prevent all cases of anorexia, it’s helpful to start treatment as soon as someone begins to have symptoms.

In addition, teaching and encouraging healthy eating habits and realistic attitudes about food and body image also might help prevent the development or worsening of eating disorders. If your child or family member decides to become vegetarian or vegan, for instance, it’s worth seeing a dietitian versed in eating disorders and touching base with your pediatrician or healthcare provider to make sure that this change occurs without a loss in nutrients.

Outlook / Prognosis

What is the outlook (prognosis) for people with anorexia?

The prognosis for anorexia varies depending on certain factors, including:

  • How long the person has had anorexia.
  • The severity of the condition.
  • The type of treatment and adherence to treatment.

Anorexia, like other eating disorders, gets worse the longer it’s left untreated. The sooner the disorder is diagnosed and treated, the better the outcome. However, people with anorexia often will not admit they have a problem and might resist treatment or refuse to follow the treatment plan.

Anorexia is a serious and potentially life-threatening eating disorder if it’s left untreated. Eating disorders, including anorexia, are among the deadliest mental health conditions, second only to opioid addiction. Individuals with anorexia are 5 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 as well as a strong commitment by the individual. Support of family members and friends can help ensure that the person receives and adheres to their needed treatment.

What are the complications of anorexia?

The medical complications and health risks of malnutrition and starvation, which are common in people who have anorexia, can affect nearly every organ in your body. In severe cases, vital organs such as your brain, heart and kidneys can sustain damage. This damage may be irreversible even after a person has recovered from anorexia.

Severe medical complications that can happen from untreated anorexia include:

In addition to physical complications, people with anorexia also commonly have other mental health conditions, including:

  • Depression, anxiety and other mood disorders.
  • Personality disorders.
  • Obsessive-compulsive disorders.
  • Alcohol use disorder and substance misuse.

If these mental health conditions are left untreated, they could lead to self-injury, suicidal thoughts or suicide attempts.

If you’re having suicidal thoughts, call the National Suicide Prevention Lifeline at 1-800-273-8255. Someone will be available to talk with you 24/7.

Living With

How do I take care of myself if I have anorexia?

It can be uncomfortable and scary, but it’s important to tell a loved one and/or your healthcare provider if you have anorexia.

If you have already been diagnosed with anorexia, there are some things you can do to manage your condition and stay committed to recovery, including:

  • Get enough sleep.
  • Don’t abuse alcohol or drugs.
  • If you take prescribed medication, be sure to take it regularly and do not miss doses.
  • If you are participating in talk therapy to treat your anorexia, be sure to see your therapist regularly.
  • Reach out to family and friends for support.
  • Consider joining a support group for people who have anorexia.
  • See your healthcare provider regularly.

How can I care for a loved one who has anorexia?

There are multiple things you can do to help and support someone with anorexia, including:

  • Learn about anorexia: Educate yourself about anorexia to better understand what they are going through. Don’t assume you know what they are experiencing.
  • Be empathetic: Don’t downplay or dismiss their feelings and experiences. Let them know that you are there to listen and support them. Try to put yourself in their shoes.
  • Encourage them to seek help and/or treatment: While having an understanding and supportive friend or family member is helpful to a person with anorexia, anorexia is a medical condition. Because of this, people with anorexia need treatment such as therapy and nutritional counseling to manage their condition. Encourage them to talk to their healthcare provider if they are experiencing the signs and symptoms of anorexia.
  • Be patient: It can take a while for someone with anorexia to get better once they’ve started treatment. Know that it is a long and complex process and that their symptoms and behaviors will eventually improve.

When should I see my healthcare provider?

If you or someone you know is experiencing signs and symptoms of anorexia, be sure to talk to a healthcare provider as soon as possible.

When should a person with anorexia go to the emergency room?

Someone with anorexia should go to the emergency room (ER) if they’re experiencing any of the following physical symptoms:

  • Unusually low blood pressure.
  • Decreased heart rate or irregular heartbeat.
  • Chest pain.
  • Seizures (due to extremely low blood sugar levels).

If you’re having thoughts of harming yourself, get to the nearest hospital as soon as possible or call the National Suicide Prevention Lifeline at 1-800-273-8255. Someone will be available to talk with you 24/7.

If you recognize suicidal behaviors in someone with anorexia, get them care as soon as possible.

A note from Cleveland Clinic

Anorexia is a serious and potentially life-threatening condition. The good news is that recovery is definitely possible. If you or someone you know is experiencing signs and symptoms of anorexia, it’s essential to seek help and care as soon as possible. It’s never too late to seek treatment, but getting help early improves the chance of a lasting recovery.

Last reviewed by a Cleveland Clinic medical professional on 11/17/2021.

References

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  • MedlinePlus. Anorexia. (https://medlineplus.gov/ency/article/000362.htm) Accessed 11/19/2021.
  • National Alliance on Mental Illness. Eating Disorders. (https://www.nami.org/Learn-More/Mental-Health-Conditions/Eating-Disorders) Accessed 11/19/2021.
  • National Eating Disorders Association. Anorexia Nervosa. (https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia) Accessed 11/19/2021.
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