Anorexia Nervosa

Anorexia nervosa is far more than just a problem with food. It's a complex psychological disorder that uses extreme control over food and weight as a way to cope with emotional problems and achieve a sense of control. People with anorexia often equate thinness with self-worth and may see weight loss as a way to achieve perfection or gain approval.

The disorder typically begins during adolescence, though it can develop at any age. What might start as simple dieting can spiral into an obsession with food, weight, and body size. Despite being underweight, people with anorexia see themselves as fat and continue restricting food intake, exercising excessively, or using other methods to lose weight.

Anorexia has the highest mortality rate of any mental disorder. Death may result from medical complications associated with starvation or from suicide. The good news is that with proper treatment, full recovery is possible. Early intervention significantly improves the chances of complete recovery and reduces the risk of the disorder becoming chronic.

Anorexia nervosa involves physical, emotional, and behavioral symptoms. The disorder can be difficult to recognize, especially in early stages, as people often hide their behaviors and deny having a problem.

Emotional and Mental Symptoms

• Intense fear of gaining weight
• Distorted body image
• Self-worth based on body weight/shape
• Denial of seriousness of low weight
• Anxiety around meals
• Depression and mood swings
• Perfectionism
• Need for control
• Difficulty concentrating
• Preoccupation with food, calories, and dieting
• Black-and-white thinking
• Low self-esteem
• Irritability
• Social isolation

Restricting Type

• Weight loss through dieting, fasting, or excessive exercise
• No regular binge eating or purging behaviors
• May follow extremely restrictive diets
• Often accompanied by compulsive exercise
• May have rigid eating rules and rituals

Binge-Eating/Purging Type

• Regular episodes of binge eating and/or purging
• Purging through vomiting, laxatives, or diuretics
• May alternate between restriction and binge/purge cycles
• Often experience more impulsivity
• Higher risk of electrolyte imbalances

Atypical Anorexia Nervosa

• All criteria for anorexia except low weight
• Significant weight loss but weight remains in normal range
• Same psychological features and medical risks
• Often overlooked due to weight bias
• Equally serious and requires treatment

The exact causes of anorexia nervosa are unknown, but it's believed to result from a complex interaction of biological, psychological, and environmental factors.

Biological Factors

• Genetics: First-degree relatives have 10x higher risk
• Brain chemistry: Imbalances in serotonin and dopamine
• Hormones: Disruptions in hunger and satiety hormones
• Temperament: Perfectionism, anxiety, obsessive traits
• Gut microbiome: Emerging research on gut-brain connection

Psychological Factors

• Perfectionism and high achievement orientation
• Low self-esteem
• Difficulty expressing emotions
• Need for control
• Black-and-white thinking patterns
• Body dissatisfaction
• History of anxiety or depression
• Obsessive-compulsive traits

Environmental and Social Factors

• Cultural pressures: Thin ideal in media and society
• Peer pressure: Diet culture and weight stigma
• Activities: Sports/careers emphasizing thinness
• Family dynamics: High expectations, criticism
• Trauma: Physical, emotional, or sexual abuse
• Major life changes: Puberty, breakups, transitions
• Bullying: Especially weight-related teasing
• Social media: Comparison and "thinspiration"

High-Risk Groups

• Adolescents and young adults
• Athletes in aesthetic sports (gymnastics, dance, figure skating)
• Models and performers
• People with Type 1 diabetes
• LGBTQ+ individuals
• Those with history of dieting
• Individuals with other mental health conditions

Anorexia nervosa affects every organ system in the body. Many complications can be reversed with treatment, but some may cause permanent damage.

Cardiovascular Complications

• Bradycardia (slow heart rate)
• Hypotension (low blood pressure)
• Heart muscle wasting
• Mitral valve prolapse
• Heart failure
• Sudden cardiac death
• Electrolyte imbalances affecting heart rhythm

Bone and Muscle

• Osteoporosis (bone loss)
• Increased fracture risk
• Muscle wasting
• Weakness and fatigue
• Growth retardation in adolescents

Endocrine System

• Amenorrhea (loss of periods)
• Infertility
• Low testosterone in males
• Thyroid hormone abnormalities
• Growth hormone resistance
• High cortisol levels

Gastrointestinal

• Delayed gastric emptying
• Constipation
• Bloating and fullness
• Liver damage
• Pancreatitis

Neurological

• Brain volume loss
• Cognitive impairment
• Difficulty concentrating
• Peripheral neuropathy
• Seizures

Other Complications

• Anemia
• Kidney problems
• Dental erosion (if purging)
• Hair loss
• Dry skin
• Poor wound healing
• Increased infection risk

Diagnosing anorexia nervosa involves a comprehensive evaluation by healthcare professionals, including medical doctors, mental health professionals, and nutritionists.

Diagnostic Criteria (DSM-5)

1. Restriction of energy intake leading to significantly low body weight
2. Intense fear of gaining weight or persistent behavior preventing weight gain
3. Disturbance in body image, undue influence of weight on self-evaluation, or denial of seriousness of low weight

Assessment Process

• Medical history: Including weight history, eating behaviors, menstrual history
• Physical examination: Vital signs, BMI, physical complications
• Psychological evaluation: Thoughts about food, weight, body image
• Nutritional assessment: Dietary intake, eating patterns
• Family assessment: Family dynamics and history

Laboratory Tests

• Complete blood count (CBC)
• Comprehensive metabolic panel
• Thyroid function tests
• Electrolyte levels
• Liver and kidney function
• Hormone levels
• Bone density scan (DEXA)
• Electrocardiogram (ECG)

Severity Levels (Based on BMI)

• Mild: BMI ≥ 17
• Moderate: BMI 16-16.99
• Severe: BMI 15-15.99
• Extreme: BMI < 15

Note: BMI is not the only indicator of severity; medical stability and functioning are also considered.

Treatment for anorexia nervosa requires a multidisciplinary approach addressing physical health, nutritional rehabilitation, and psychological issues. The level of care depends on medical stability and severity.

Levels of Care

Inpatient Hospitalization

• For medical stabilization
• Severe malnutrition (BMI < 15)
• Medical complications
• Suicidal ideation
• Failure of outpatient treatment

Residential Treatment

• 24-hour care in non-hospital setting
• Medically stable but need intensive support
• Structured meals and therapy
• Typical stay: 1-3 months

Partial Hospitalization (PHP)

• Day treatment program
• 5-7 days per week
• Return home in evenings
• Supervised meals and intensive therapy

Intensive Outpatient (IOP)

• 3-4 days per week
• Several hours per day
• Group and individual therapy
• Meal support

Outpatient Treatment

• Weekly therapy sessions
• Regular medical monitoring
• Nutritional counseling
• Psychiatry as needed

Treatment Components

Medical Management

• Monitoring vital signs and lab values
• Managing medical complications
• Refeeding carefully to avoid refeeding syndrome
• Bone health management
• Hormone replacement if needed

Nutritional Rehabilitation

• Gradual weight restoration
• Meal planning and support
• Education about nutrition
• Challenging food rules and fears
• Family meal support

Psychotherapy

Family-Based Treatment (FBT/Maudsley)

• Gold standard for adolescents
• Parents take charge of refeeding
• Gradual return of control to patient
• Family therapy sessions

Cognitive Behavioral Therapy (CBT-E)

• Enhanced CBT for eating disorders
• Addresses thoughts and behaviors
• Challenges distorted beliefs
• Relapse prevention

Other Therapies

• Dialectical Behavior Therapy (DBT)
• Acceptance and Commitment Therapy (ACT)
• Interpersonal Therapy (IPT)
• Art/Music/Movement therapy
• Group therapy

Medications

• No medications specifically approved for anorexia
• SSRIs may help with co-occurring anxiety/depression
• Olanzapine sometimes used for weight gain
• Supplements for nutritional deficiencies
• Medications for bone health

Recovery from anorexia nervosa is possible but often takes time. It's not just about weight restoration but also involves healing the relationship with food, body, and self.

Recovery Statistics

• 45% achieve full recovery
• 35% improve considerably
• 20% develop chronic course
• Recovery typically takes 4-7 years
• Earlier intervention improves outcomes

Factors Associated with Better Outcomes

• Younger age at onset
• Shorter duration of illness
• Higher BMI at start of treatment
• Good family support
• Motivation to recover
• Absence of purging behaviors
• No other psychiatric conditions

Stages of Recovery

1. Medical stabilization: Addressing immediate health risks
2. Nutritional rehabilitation: Weight restoration
3. Psychological work: Addressing underlying issues
4. Relapse prevention: Developing coping skills
5. Maintenance: Ongoing support and monitoring

Challenges in Recovery

• Fear of weight gain
• Body image distress during weight restoration
• Hypermetabolism requiring high calories
• Gastrointestinal discomfort
• Mood swings and anxiety
• Social challenges
• Risk of relapse

Relapse Prevention

• Continue therapy after weight restoration
• Regular medical monitoring
• Maintain support system
• Address co-occurring conditions
• Develop healthy coping strategies
• Challenge perfectionism
• Practice self-compassion

How to Help

• Learn about eating disorders
• Approach with compassion, not judgment
• Focus on feelings and relationships, not food
• Avoid comments about appearance
• Don't become the "food police"
• Encourage professional help
• Be patient - recovery takes time

What to Say

• "I'm concerned about you"
• "I'm here to support you"
• "You deserve help and recovery"
• "Your life has value beyond your appearance"
• "Recovery is possible"

What NOT to Say

• "Just eat"
• "You look so thin/sick"
• "I wish I had your willpower"
• "You look healthy/better" (during recovery)
• Comments about food choices
• Diet or weight talk

Supporting Recovery

• Create a non-judgmental environment
• Participate in family therapy if asked
• Remove scales and diet products
• Model healthy relationship with food
• Plan non-food activities
• Celebrate non-appearance achievements
• Take care of your own mental health

While not all cases of anorexia can be prevented, certain strategies may reduce risk:

Individual Prevention

• Develop healthy relationship with food
• Practice body acceptance
• Build self-esteem beyond appearance
• Learn healthy coping strategies
• Limit social media exposure
• Seek help for anxiety or depression

Family Prevention

• Avoid diet talk and weight comments
• Model healthy eating behaviors
• Focus on health, not weight
• Encourage diverse interests and skills
• Build children's self-esteem
• Family meals without distraction
• Address perfectionism early

Community Prevention

• Media literacy education
• Challenge weight stigma
• Promote body diversity
• Early screening in schools
• Training for coaches and teachers
• Access to mental health resources