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What is anorexia nervosa?

Anorexia nervosa is a potentially life-threatening eating disorder. It is a serious psychological disorder characterized by either a significantly reduced appetite or complete aversion to eating.

A patient with anorexia nervosa, often just called "anorexia" (although the meaning is different), has a distorted body image and an exaggerated fear of becoming overweight or obese - so a deliberate effort is made to lose weight.

This Medical News Today (MNT) article provides essential information on anorexia nervosa, describing what it is and what causes it, its symptoms, how it is diagnosed, possible treatment options, and complications.

What is anorexia nervosa?

Anorexia should not be confused with anorexia nervosa.

  • Anorexia is a general loss of appetite, or a loss of interest in food.
  • Anorexia nervosa is a serious mental illness. Patients have not "lost" interest in food, they have intentionally restricted their food intake because of an irrational fear of being or becoming fat.

However, lay people often use the term "anorexia" when referring to the serious psychological disorder.

According to the National Library of Medicine1, anorexia nervosa is an eating disorder that makes the patient lose more weight than is considered healthy for his or her height and age.

A person with anorexia disorder may be underweight, but still has an intense fear of putting on weight. They may do too much exercise, diet, use laxatives and other methods to get leaner.

Anorexia nervosa typically begins during a person's teenage years or early adulthood. It is the third most common chronic illness among teenagers.

ANAD2 (National Association of Anorexia Nervosa and Associated Disorders) says that between 85% to 90% of all patients with anorexia nervosa or bulimia nervosa are female.

Many studies have found that the risk of suicide among patients with anorexia nervosa is high. A study published in PLoS ONE3 found that among eating disorders, anorexia nervosa has the highest rates of completed suicides, but not attempted suicides. However, S. Coren and P. L. Hewitt wrote in the American Journal of Public Health14 that "(our) findings suggest that the suicide rate is not elevated among individuals currently suffering from anorexia nervosa."

James Lock, MD, PhD, a professor of psychiatry and behavioral sciences at Stanford University Medical School says that anorexia nervosa kills approximately 1 in every 10 patients4 (all causes, not just suicide).

What are the causes of anorexia nervosa?

Anorexia nervosa has no single cause. The National Health Service5, UK, says that the majority of experts believe the mental disorder is caused by a combination of biological, environmental and psychological factors.

Some individuals are thought to have personality traits which make them more susceptible to developing the disease.

Being underweight and not having a normal diet may have an effect on the brain which reinforces behaviors and obsessive thoughts related to anorexia nervosa. In other words, under-eating and being underweight can set off a cycle of further weight loss and under-eating.

The following risk factors have been associated with anorexia nervosa:

  • Being overly obsessed with rules
  • Having a tendency towards depression
  • Being overly worried about one's weight and shape
  • Being excessively worried, doubtful and/or scared about the future
  • Being perfectionist
  • Having a negative self image
  • Having eating problems during early childhood or infancy
  • Having had an anxiety disorder during childhood
  • Holding specific cultural/social ideas regarding beauty and health
  • Inhibition - the individual restrains or controls his or her behavior and expression

Environmental factors - may include the hormonal changes that occur during puberty, plus feelings of anxiety, stress and low self-esteem.

Many experts believe that some young females who in Western cultures are exposed to multiple messages through the media that being thin is beautiful, are more susceptible to developing anorexia nervosa. However, research carried out in the University of Granada, Spain, found the incidence of eating disorders was considerably higher among Muslim adolescents than their Christian peers.

Other environmental factors some experts believe may contribute include physical abuse, sexual abuse, issues with family relationships, being bullied, other school stress (e.g. exams), bereavement, and a stressful life event, such as the breakdown of a relationship or becoming unemployed.

Biological factors - according to NEDA6 (National Eating Disorders Association), studies are finding that in some people with eating disorders certain brain chemicals that control digestion, appetite and hunger may be unbalanced. Nobody is sure what the implications of this might be - further studies are underway to find out.

Experts believe susceptibility to eating disorders may be partly driven by a person's genes. In many cases, anorexia nervosa, bulimia nervosa and other eating disorders have been found to run in families.

What are the signs and symptoms of anorexia nervosa?

A symptom is something the patient feels and describes, such as pain, while a sign can be detected by the patient and others, such as a rash.

According to the University of Maryland Medical Center15, severe weight loss is the primary sign of anorexia nervosa. Patients will typically try to bring their body weight down by severely restricting their food intake.

In order to speed up weight loss, individuals may exercise excessively, and/or engage in binging and purging, as people with bulimia nervosa do. They may take laxatives and vomit after eating.

In all cases, the patient insists that she or he is overweight.

Physical signs and symptoms

  • Severe weight loss
  • Listlessness, fatigue, exhaustion.
  • Hypotension - blood pressure is below normal
  • Hypothermia - low body temperature
  • Upset stomach
  • Stomach is bloated
  • Dry skin
  • Cold hands and feet
  • Swollen hands and feet
  • Alopecia - hair loss
  • Loss of menstruation (or much less frequent menstruation)
  • Infertility
  • Insomnia
  • Loss of bone density (osteoporosis)
  • Brittle nails
  • Arrhythmia - irregular/abnormal heart rhythms
  • Bad breath and tooth decay - this is caused by the acid in vomit
  • Lanugo - fine downy hair growing all over the body
  • More facial hair
  • Constipation
  • Lightheadedness or dizziness

Psychological signs and symptoms

  • Underweight patients insists they are overweight
  • Vomiting after meals
  • Patients may frequently weigh themselves, look at their bodies in the mirror, and measure themselves
  • Obsession with food - the patient may spend a long time reading recipes and cookery books
  • Lying about what they have eaten
  • Not eating, refusing to eat
  • Lack of emotion
  • Depressed mood
  • Reduced libido (sex drive)
  • Memory loss
  • Self denial - patients refuse to acknowledge they have a problem or serious illness
  • Obsessive-compulsive behavior
  • Irritability
  • Over-exercising

Diagnosing anorexia nervosa

Patients who are diagnosed with eating disorders early on and receive prompt treatment tend to have much better outcomes. According to the journal American Family Physician7, "A good medical history is the most powerful tool."

The family physician (primary care physician, general practitioner) will initially talk to the patient and ask questions which may include:

  • Have you recently lost a great deal of weight?
  • Have you recently lost weight rapidly?
  • Do you find yourself feeling overweight, even though others tell you that you are thin?
  • (if the patient is female) Have your periods stopped? (if so, when and for how long?)

How the doctor interprets the patient's answers will depend on the level of cooperation he or she receives. People with anorexia nervosa tend to be resistant to opening up and speaking frankly about themselves.

Diagnosing eating disorders can be challenging. The American Academy of Pediatrics8 says that many patients go undiagnosed for several years, especially those who were once obese.

If the physician detects a low BMI (body mass index), heart rhythm irregularities, skin changes, gastrointestinal disturbances, and other signs pointing towards anorexia nervosa, further diagnostic tests may be ordered to rule out other underlying medical conditions.

The following medical problems often have similar signs and symptoms associated with eating disorders: diabetes, Addison's disease, chronic infections, malabsorption, immunodeficiency, IBS (inflammatory bowel disease), cancer, and hyperthyroidism.

Diagnostic tests may include:

  • Blood tests - a complete blood count, and also tests to check levels of electrolytes and protein. Blood tests can also show whether the kidneys, liver and thyroid are functioning properly.
  • Imaging scans - to check for heart problems, broken bones, and pneumonia.
  • Electrocardiogram - to check for heart irregularities.

Diagnostic criteria for anorexia nervosa

The American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders (DSM), which includes the diagnostic criteria for anorexia nervosa. Patients should meet these criteria (below includes updates from the fifth edition - DSM-5):

  • The patient refuses to maintain a body weight that is at least the minimal normal weight for his or her height and age. (DSM-59 no longer uses the term "refusal.... since that implies intention on the part of the patient and can be difficult to assess.")
  • Even though the patient is underweight, there is an intense fear of becoming fat or gaining weight.
  • The patient refuses to acknowledge they have a serious low body weight problem, or they have a distorted image of their shape or appearance.
  • In females, the absence of menstruation for at least three consecutive menstrual cycles is no longer a required criterion, according to the updated DSM-59.

Many medical professionals find the DSM criteria too strict because it does not include patients who clearly have an eating disorder and require medical help.

What are the treatment options for anorexia nervosa?

Ideally, treatment should consist of a combination of medication, psychotherapy, family therapy and nutrition counseling.

Although getting the patient with anorexia to become actively involved in treatment is sometimes challenging, her or his participation is important. Cooperation and acknowledgement that there is a medical and psychological problem may fluctuate. Treatment is often long-term, and the patient may relapse, especially when experiencing periods of stress.

The patient needs a comprehensive treatment plan that is tailored to meet his or her requirements. The treatment has the following goals:

  • Restoring the patient's body weight to a healthy level.
  • Treating emotional problems, including low self-esteem.
  • Addressing distorted thinking.
  • Helping the patient develop behavioral changes that will persist over the long term.

Psychotherapy - individual counseling concentrates on changing the way the patient thinks (cognitive therapy) and behaves (behavioral therapy).

The patient learns how to develop healthy attitudes towards food and body weight. Effective ways of responding to stressful or difficult situations are also learned.

Support from family and friends is a crucial component to successful and lasting outcomes. Family members need to understand anorexia nervosa and be able to rapidly identify its signs and symptoms. Family therapy has been shown to help patients considerably.

A team from the Stanford University School of Medicine, Lucile Packard Children's Hospital and the University of Chicago showed that family-based therapy10, in which parents of teenagers with anorexia nervosa are enlisted to interrupt their child's disordered behaviors, is twice as likely to lead to full remission of the disease. The study findings were published in Archives of General Psychiatry.

Medication - there is no medication specifically for anorexia nervosa. The doctor may prescribe drugs to control anxiety, OCD (obsessive-compulsive disorder), or anti-depressants.

Selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant, can only be prescribed when the patients' body-weight is at least 95% of normal for their height and age.

Olanzapine - a medication originally designed to treat psychosis, may be helpful in cases where the patient is over-anxious about his or her diet and weight.

Nutrition counseling - the aim is to help the patient regain a healthy approach to body weight, food and eating habits. Sometimes this requires comprehensive education on the role of a balanced diet in maintaining good health.

Hospitalization - in cases of severe weight-loss or malnutrition, persistent refusal to eat, or psychiatric emergencies, it may be necessary to hospitalize the patient.

In the UK, under the Mental Health Act, if the patient is severely ill and continues to refuse treatment they may have to undergo compulsory treatment, according to the National Health Service11.

What are the complications?

The complications of anorexia nervosa are much less likely to occur if the patient is diagnosed early and receives prompt and proper treatment.

  • Death - the South Carolina Department of Mental Health12 states that eating disorders have the highest mortality rates of any mental illness. It also quotes a statistic that between 5% to 10% of anorexics die within 10 years of contracting the disease (18% to 20% within 20 years).

  • Cardiovascular problems - according to the Wexner Medical Center13, at the Ohio State University, up 95% of patients who are hospitalized have low heart rates. Changes in heartbeat raise the risk of myocardial damage (damage to the heart muscle).

  • Hematological problems - there is a much higher risk of developing leukopenia (low white blood cell count) and anemia (low red blood cell count).

  • Gastrointestinal problems - movement in the intestines slows down significantly if the person is severely underweight and eating too little. This resolves when they start eating well.

  • Kidney problems - people with anorexia nervosa commonly suffer from dehydration, which in turn leads to highly concentrated urine. The patient is more likely to produce more urine (polyuria) because the kidneys cannot concentrate urine properly. When the patient's weight returns to normal, the kidneys usually recover.

  • Hormonal problems - some anorexic patients have lower levels of growth hormones, which may be why some adolescent patients experience growth retardation. When the patient starts eating a healthy diet, normal growth resumes.

  • Bone fractures - these are much more likely to occur in people with anorexia nervosa. Patients whose bones have not fully grown yet have a significantly higher risk of developing osteopenia (reduced bone tissue) and bone loss (osteoporosis).

Video - My experience with anorexia nervosa

In this video, by the National Health Service, UK, Katie shares her experiences of life with anorexia and explains how she recovered.

Written by Christian Nordqvist


Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

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