Anorexia nervosa is an
eating disorder that causes people to obsess about their weight and the
food they eat. People with anorexia nervosa attempt to maintain a weight
that's far below normal for their age and height. To prevent weight
gain or to continue losing weight, people with anorexia nervosa may
starve themselves or exercise excessively.
Anorexia (an-oh-REK-see-uh) nervosa isn't really about food. It's an
unhealthy way to try to cope with emotional problems. When you have
anorexia nervosa, you often equate thinness with self-worth.
Anorexia nervosa can be difficult to overcome. But with treatment, you
can gain a better sense of who you are, return to healthier eating
habits and reverse some of anorexia's serious complications.
Some people with anorexia lose weight mainly through severely
restricting the amount of food they eat. They may also try to lose
weight by exercising excessively. Others with anorexia engage in binging
and purging, similar to bulimia. They control calorie intake by
vomiting after eating or by misusing laxatives, diuretics or enemas.
No matter how weight loss is achieved, anorexia has a number of physical, emotional and behavioral signs and symptoms.
Physical anorexia symptoms
Physical signs and symptoms of anorexia include:
* Extreme weight loss
* Thin appearance
* Abnormal blood counts
* Dizziness or fainting
* A bluish discoloration of the fingers
* Brittle nails
* Hair that thins, breaks or falls out
* Soft, downy hair covering the body
* Absence of menstruation
* Dry skin
* Intolerance of cold
* Irregular heart rhythms
* Low blood pressure
* Swelling of arms or legs
Emotional and behavioral anorexia symptoms
Emotional and behavioral characteristics associated with anorexia include:
* Refusal to eat
* Denial of hunger
* Excessive exercise
* Flat mood, or lack of emotion
* Social withdrawal
* Preoccupation with food
* Reduced interest in sex
* Depressed mood
* Possible use of herbal products or diet aids
Anorexia red flags to watch for
It may be hard to notice signs and symptoms of anorexia because people
with anorexia often go to great lengths to disguise their thinness,
eating habits or physical problems.
If you're concerned that a loved one may have anorexia, watch for these possible red flags:
* Skipping meals
* Making excuses for not eating
* Eating only a few certain "safe" foods, usually those low in fat and calories
* Adopting rigid meal or eating rituals, such as cutting food into tiny pieces or spitting food out after chewing
* Cooking elaborate meals for others but refusing to eat
* Repeated weighing of themselves
* Frequent checking in the mirror for perceived flaws
* Complaining about being fat
* Not wanting to eat in public
When to see doctor
Anorexia, like other eating disorders, can take over your life. You may
think about food all of the time, spend hours agonizing over options in
the grocery store and exercise to exhaustion. You also may have a host
of physical problems that make you feel generally miserable, such as
dizziness, constipation, fatigue and frequently feeling cold. You may be
irritable, angry, moody, sad, anxious and hopeless. You might visit
pro-anorexia Web sites, refer to the disease as your "friend," cover up
in layers of heavy clothing, and try to subsist on a menu of lettuce,
carrots, popcorn and diet soda.
If you're experiencing any of these problems, or if you think you may
have an eating disorder, get help. If you're hiding your anorexia from
loved ones, try to find a confidant you can talk to about what's going
Unfortunately, many people with anorexia don't want treatment, at least
initially. Their desire to remain thin overrides concerns about their
health. If you have a loved one you're worried about, urge her or him to
talk to a doctor.
It's not known specifically what causes some people to develop anorexia.
As with many diseases, it's likely a combination of biological,
psychological and sociocultural factors.
Biological. Some people may be genetically vulnerable to
developing anorexia. Young women with a biological sister or mother with
an eating disorder are at higher risk, for example, suggesting a
possible genetic link. Studies of twins also support that idea. However,
it's not clear specifically how genetics may play a role, although
researchers have discovered an area on chromosome 1 that appears to be
associated with an increased susceptibility to anorexia nervosa.
It may also be that some people have a genetic tendency toward
perfectionism, sensitivity and perseverance, all traits associated with
anorexia. There's also some evidence that serotonin — one of the brain
chemicals involved in depression — may play a role in anorexia.
* Psychological. People with anorexia may have psychological and
emotional characteristics that contribute to anorexia. They may have low
self-worth, for instance. They may have obsessive-compulsive
personality traits that make it easier to stick to strict diets and
forgo food despite being hungry. They may have an extreme drive for
perfectionism, which means they may never think they're thin enough.
* Sociocultural. Modern Western culture often cultivates and
reinforces a desire for thinness. The media are splashed with images of
thin models and actors. Success and worth are often equated with being
thin. Peer pressure may fuel the desire to be thin, particularly among
young girls. However, anorexia and other eating disorders existed
centuries ago, suggesting that sociocultural values aren't solely
Certain risk factors increase the risk of anorexia, including:
* Being female. Anorexia is more common in girls and women. However,
boys and men have been increasingly developing eating disorders,
perhaps because of growing social pressures.
* A young age. Anorexia is more common among teenagers. Still,
people of any age can develop this eating disorder, though it's rare in
people older than 40. Teenagers may be more susceptible because of all
of the changes their bodies go through during puberty. They also may
face increased peer pressure and may be more sensitive to criticism or
even casual comments about weight or body shape.
* Genetics. Researchers have found an area on chromosome 1 that
appears to be linked to an increased risk of anorexia nervosa.
Additionally, anorexia nervosa runs in families, another factor that
suggests a genetic component. Women with a first-degree relative — a
parent, sibling or child — who had the disease have a dramatically
increased risk of developing anorexia nervosa.
* Weight changes. When people lose or gain weight — on purpose or
unintentionally — those changes may be reinforced by positive comments
from others if weight was lost, or by negative comments if there was a
weight gain. Such changes and comments may trigger someone to start
dieting to an extreme.
* Transitions. Whether it's a new school, home or job, a
relationship breakup, or the death or illness of a loved one, change can
bring emotional distress and increase the risk of anorexia nervosa.
* Sports, work and artistic activities. Athletes, actors and
television personalities, dancers, and models are at higher risk of
anorexia. For some, such as ballerinas, ultrathinness may even be a
professional requirement. Sports associated with anorexia include
running, wrestling, figure skating and gymnastics. Professional men and
women may believe they'll improve their upward mobility by losing
weight, and then take it to an extreme. Coaches and parents may
inadvertently raise the risk by suggesting that young athletes lose
* Media and society. The media, such as television and fashion
magazines, frequently feature a parade of skinny models and actors. But
whether the media merely reflect social values or actually drive them
isn't clear-cut. In any case, these images may seem to equate thinness
with success and popularity.
Anorexia can have numerous complications. At its most severe, it can be
fatal. Death may occur suddenly — even when someone is not severely
underweight. This may result from abnormal heart rhythms (arrhythmias)
or an imbalance of electrolytes — minerals such as sodium, potassium and
calcium that maintain the balance of fluids in your body.
Complications of anorexia include:
* Heart problems, such as mitral valve prolapse, abnormal heart rhythms and heart failure
* Bone loss, increasing risk of fractures later in life
* In females, absence of a period
* In males, decreased testosterone
* Gastrointestinal problems, such as constipation, bloating or nausea
* Electrolyte abnormalities, such as low blood potassium, sodium and chloride
* Kidney problems
If a person with anorexia becomes severely malnourished, every organ in
the body can sustain damage, including the brain, heart and kidneys.
This damage may not be fully reversible, even when the anorexia is under
In addition to the host of physical complications, people with anorexia
also commonly have other mental disorders as well. They may include:
* Anxiety disorders
* Personality disorders
* Obsessive-compulsive disorders
* Drug abuse
Preparing for your appointment
Treatment of anorexia is generally done using a team approach that
includes medical providers, mental health providers and dietitians, all
with experience in eating disorders.
Here's some information to help you get ready for your appointments, and
what to expect from your doctor and other health providers.
What you can do
* Write down any symptoms you're experiencing, including any that
may seem unrelated to the reason for which you scheduled the
* Write down key personal information, including any major stresses or recent life changes.
* Make a list of all medications, vitamins and supplements that you're taking.
* Ask a family member or friend to come with you, if possible.
Sometimes it can be difficult to remember all of the information
provided to you during an appointment. Someone who accompanies you may
remember something that you missed or forgot. A family member may also
be able to give your doctor a fuller picture of your home life.
* Write down questions to ask your doctor so you'll remember to cover everything you wanted to.
Some potential questions you might want to ask your doctor or other health care provider include:
* What kinds of tests do I need? Do these tests require any special preparation?
* Is this condition temporary or long lasting?
* What treatments are available, and which do you recommend?
* Is there a generic alternative to the medicine you're prescribing me?
* Will my periods begin again?
* Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you've prepared to ask, don't hesitate
to ask questions of any of your providers anytime that you don't
What to expect from your doctor
Your doctor or other health care provider is likely to ask you a number of questions, such as:
* How long have you been worried about your weight?
* Do you exercise? How often do you exercise?
* Have you found any other ways to lose weight?
* Are you having any physical symptoms?
* Have you ever vomited because you were uncomfortably full?
* Have others expressed concern that you're too thin?
* Do you think about food often?
* Do you ever eat in secret?
* Have any of your family members ever had symptoms of an eating
disorder or have any been diagnosed with an eating disorder?
Tests and diagnosis
When doctors suspect someone has anorexia, they typically run a battery
of tests and exams to help pinpoint a diagnosis, rule out medical causes
for the weight loss and also check for any related complications.
These exams and tests generally include:
* Physical exam. This may include measuring your height and weight;
checking your vital signs, such as heart rate, blood pressure and
temperature; checking your skin and nails for dryness or other problems;
listening to your heart and lungs; and examining your abdomen.
* Laboratory tests. These may include a complete blood count (CBC),
as well as more specialized blood tests to check electrolytes and
protein as well as functioning of your liver, kidney and thyroid. A
urinalysis also may be done.
* Psychological evaluation. A doctor or mental health provider can
assess thoughts, feelings and eating habits. Psychological
self-assessments and questionnaires also are used.
* Other studies. X-rays may be taken to check for broken bones,
pneumonia or heart problems. Electrocardiograms may be done to look for
heart irregularities. Bone density testing may be done to check your
bone health. Testing may also be done to determine how much energy your
body uses, which can help in planning nutritional requirements.
Diagnostic criteria for anorexia
To be diagnosed with anorexia, you generally must meet criteria spelled
out in the Diagnostic and Statistical Manual of Mental Disorders (DMS),
published by the American Psychiatric Association.
DSM diagnostic criteria for anorexia are:
* Refusal to maintain a body weight that is at or above the minimum normal weight for your age and height
* Intense fear of gaining weight or becoming fat, even though you're underweight
* Denying the seriousness of having a low body weight, or having a distorted image of your appearance or shape
* In women who've started having periods, the absence of a period for at least three consecutive menstrual cycles
Some medical professionals believe these criteria are too strict or
don't accurately reflect symptoms in some people. Some people may not
meet all of these criteria but still have an eating disorder and need
Treatments and drugs
When you have anorexia, you may need several types of treatment. If your
life is in immediate danger, you may need treatment in a hospital
emergency department for such issues as a heart rhythm disturbance,
dehydration, electrolyte imbalances or psychiatric problems.
Here's a look at what's commonly involved in treating people with anorexia:
Because of the host of complications anorexia causes, you may need
frequent monitoring of vital signs, hydration level and electrolytes, as
well as related physical conditions. In severe cases, people with
anorexia may initially require feeding through a tube that's placed in
their nose and goes to the stomach (nasogastric tube). A primary care
doctor may be the one who coordinates care with the other health care
professionals involved. Sometimes, though, it's the mental health
provider who coordinates care.
Restoring a healthy weight
The first goal of treatment is getting back to a healthy weight. You
cannot recover from an eating disorder without restoring an appropriate
weight and learning proper nutrition. A dietitian can offer guidance on a
healthy diet, including providing specific meal plans and calorie
requirements that will help you meet your weight goals. Your family will
also likely be involved in helping you maintain healthy-eating habits.
Individual, family-based and group therapy may all be beneficial.
* Individual therapy. This type of therapy can help you deal with
the behavior and thoughts that contribute to anorexia. You can gain a
healthier self-esteem and learn positive ways to cope with distress and
other strong feelings. A type of talk therapy called cognitive
behavioral therapy (CBT) is commonly used but lacks strong evidence that
it's superior to other forms of therapy for treating anorexia nervosa. A
mental health provider can help assess the need for psychiatric
hospitalization or day treatment programs.
* Family-based therapy. This therapy begins with the assumption that
the person with the eating disorder is no longer capable of making
sound decisions regarding his or her health and needs help from the
family. An important part of family-based therapy is that the family is
involved in making sure that healthy-eating patterns are followed. This
type of therapy can help resolve family conflicts and muster support
from concerned family members. Family-based therapy can be especially
important for children with anorexia who still live at home.
* Group therapy. This type of therapy gives you a way to connect to
others facing eating disorders. And informal support groups may
sometimes be helpful. However, be careful with informal groups that
aren't led by a mental health professional. For some people with
anorexia, support groups might result in competitions to be the thinnest
There are no medications specifically designed to treat anorexia because
they've shown limited benefit in treating this eating disorder.
However, antidepressants or other psychiatric medications can help treat
other mental disorders you may also have, such as depression or
In cases of medical complications, psychiatric emergencies, severe
malnutrition or continued refusal to eat, hospitalization may be needed.
Hospitalization may be on a medical or psychiatric ward. Some clinics
specialize in treating people with eating disorders. Some may offer day
programs or residential programs, rather than full hospitalization.
Specialized eating disorder programs may offer more intensive treatment
over longer periods of time. Also, even after hospitalization ends,
ongoing therapy and nutrition education are highly important to
Treatment challenges in anorexia
Some cases of anorexia are much more severe than others. Less severe
cases may take less time for treatment and recovery. One of the biggest
challenges in treating anorexia is that people may not want treatment,
may think they don't need it or may be concerned about weight gain. And,
some people with anorexia promote it as a lifestyle choice. They don't
consider it an illness. Pro-anorexia (pro-ana) Web sites can be found on
the Internet, and some even offer tips on which foods to avoid and how
to fight hunger pangs.
Even if you do want to get better, the pull of anorexia can be difficult
to overcome. Anorexia is often an ongoing, lifelong battle. Although
symptoms may subside, you remain vulnerable and may have a relapse
during periods of high stress or during triggering situations. For
example, anorexia symptoms may subside during pregnancy only to return
once your baby has been delivered. Ongoing therapy or periodic
appointments during times of stress may be helpful.
Lifestyle and home remedies
When you have anorexia, it can be difficult to take care of yourself
properly. In addition to professional treatment, follow these steps:
* Stick to your treatment plan. Don't skip therapy sessions and try
not to stray from meal plans, even if they make you uncomfortable.
* Talk to your doctor about appropriate vitamin and mineral
supplements. If you're not eating well, chances are your body isn't
getting all of the nutrients it needs.
* Don't isolate yourself from caring family members and friends who
want to see you get healthy. Understand that they have your best
interests at heart.
* Resist urges to weigh yourself or check yourself in the mirror
frequently. These may do nothing but fuel your drive to maintain
Although yoga has not yet been well studied as a treatment for people
with eating disorders, some research has found that yoga may be
beneficial as an additional treatment. It may help people with eating
disorders by increasing a sense of well-being and promoting relaxation.
Coping and support
You may find it difficult to cope with anorexia when you're hit with
mixed messages by the media, culture, and perhaps your own family or
friends. You may even have heard people joke that they wish they could
have anorexia for a while so that they could lose weight.
So how do you cope with a disease that can be deadly when you may be getting messages that being thin is a sign of success?
* Remind yourself what a healthy weight is for your body, especially
at times when you see images that may trigger your desire to restrict
* Don't visit pro-anorexia Web sites. These sites can encourage you
to maintain dangerous habits and trigger relapses. Anorexia isn't a
lifestyle choice. It's a disease.
* Acknowledge that you may not always be the best judge of whether you're eating enough or are at a healthy weight.
* Identify problem situations that are likely to trigger thoughts or
behavior that may contribute to your anorexia so that you can develop a
plan of action to deal with them.
* Look for positive role models. Remind yourself that ultrathin
models or actors showcased in women's magazines or gossip magazines may
not represent healthy bodies.
If you're interested in joining a support group, ask your doctor if he
or she knows if there's a group in your area, or call the National
Association of Anorexia Nervosa and Associated Eating Disorders' (ANAD)
helpline at 630-577-1330. (This is not a free phone call.) You can also
find information on its Web site.
There's no guaranteed way to prevent anorexia or other eating disorders.
Primary care physicians (pediatricians, family physicians and
internists) may be in a good position to identify early indicators of an
eating disorder and prevent the development of full-blown illness. They
can ask questions about eating habits and satisfaction with appearance
during routine medical appointments, for instance.
If you notice a family member or friend with low self-esteem, severe
dieting and dissatisfaction with appearance, consider talking to him or
her about these issues. Although you may not be able to prevent an
eating disorder from developing, you can talk about healthier behavior
or treatment options.