Dr. Angela Hanford
The effects of anorexia are felt by not only the individual who struggles with the disorder, but by family members, friends, and society in general. Although anorexia nervosa is reported more in females (APA, 2013), it is important to remember that males do struggle with anorexia nervosa. Also, anorexia nervosa most often begins during the teenage or young adult years (APA, 2013).
Anorexia Nervosa Defined
Anorexia nervosa is a specific type of eating disorder that is listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (APA, 2013). In order for someone to be diagnosed with anorexia nervosa, an individual must meet specific criteria, such as:
- Restricting food
- The reduction in food results in significantly low body weight. Whether someone has low body weight is determined by factors such as age and sex. For children or teenagers, the low weight may not be actual weigh loss but not making the weight gains that would be expected.
- Someone who is anorexic also experiences extreme fear about gaining weight. They may also engage in activities that prevent weight gain (e.g., laxative use, vomiting, excessive exercise).
- There is also some type of distortion in perception or thinking. Specifically, someone with anorexia nervosa may not recognize how serious their condition actually is, experience distortion in how they perceive their weight or body or place emphasis on weight or how their body looks when they evaluate themselves.
Anorexia can be of the “restricting type” or the “binge-eating/purging type.” As the name implies, the binge-eating/purging type of anorexia nervosa is when someone engages in binge eating or purging (e.g., vomiting, diuretics). This is distinct from bulimia nervosa (BN) in that someone with BN does not have the significantly low body weight (APA, 2013).
Sometimes people will meet all criteria for anorexia nervosa except for the significant weight loss. When this occurs, the diagnosis of other specified feeing or eating disorder is given (APA, 2013).
Individuals who are diagnosed with anorexia nervosa also frequently meet criteria for another diagnosis. For example, diagnoses that often occur with anorexia nervosa include depressive disorders, anxiety disorder, and bipolar disorders (APA, 2013).
Sometimes, especially individuals with the restricting type of anorexia nervosa, report obsessive compulsive disorder. In addition, substance use disorders are often also reported by those diagnosed with anorexia nervosa, especially those with binge-eating/purging type (APA, 2013; Fairburn & Brownell, 2002).
Anorexia nervosa can have serious physical consequences and can be life threatening (APA, 2013). This is one reason why seeing the appropriate treatment is so important. For example, an increased risk for heart problems (e.g., bradycardia), hypothermia, organ problems, loss of bone mineral density, and blood pressure problems have been associated with anorexia nervosa.
Women who restrict their caloric intake can also experience the ceasing of periods (i.e., amenorrhea) or the delay in period for those who are pre-puberty. Lanugo, “a fine downy body hair” can also develop (APA, 2013).
When purging occurs with anorexia nervosa, this brings additional risk for medical complications (APA, 2013). For example, abnormalities in lab tests (e.g., electrolyte imbalances) can occur as the result of purging (e.g., vomiting). Vomiting can lead to teeth erosion because of the stomach acid, along with enlargement of the salivary glands. Laxatives can result in difficulties with bowel movements.
These are only an overview of some of the medial complications associated with anorexia nervosa.
Risk Factors for Anorexia Nervosa
A frequently asked questions about anorexia nervosa is: why does someone develop anorexia nervosa? The answer to this question is complicated and involves many possible factors. There is not one single reason that has been determined to cause anorexia nervosa. Rather, there are a likely a variety of risk factors that are involved in the development of anorexia nervosa symptoms.
The following are a list of risk factors that have been observed to be related to anorexia nervosa.
The influence of culture on body image is very evident in our society that is inundated by social media and the internet. There are even websites and social media pages (e.g., Instagram) that promote anorexia and provide tips on how to better “succeed” in anorexic behaviors (“pro-ana”).
Although anorexia nervosa is reported throughout different cultures, it has the highest rates in “post-industrialized, high income countries” (APA, 2013). However, not everyone in a given culture develops an eating disorder. The answer to why some people develop eating disorders and others do not is not completely known, but there are a variety of hypotheses given to explain this phenomenon.
For example, researchers have looked at the perceived ideal body size in a given culture (e.g., thin) and noticed that exposure to this ideal is associated with an increase in body dissatisfaction (NEDA, 2018). There is also a connection between anorexia nervosa and cultures where there is a significant focus on and positive attention to being thin (APA, 2013).
Furthermore, activities that promote being thin have also been connected to increased risk for anorexia nervosa. Examples of such activities include modeling and certain sports (e.g., dance, gymnastics). An additional factor that could influence the development of anorexia nervosa is the experience of weight prejudices or bullying.
2.Trauma and Other Stressors
There is a connection between traumatic events and eating disorders. For example, researchers examining emotional, physical, and sexual abuse did find a connection between abuse and eating disorders (Kong & Bernstein, 2009; Brewerton, 2007). Furthermore, it does not have to be what is traditionally thought of as trauma (e.g., sexual abuse) to have an impact on one’s life. In fact, anorexia nervosa often begins after a significant life stressor (APA, 2013). This could be after a move, relational loss, or any other significant life event.
There are certain emotional or temperamental traits that have been associated with eating disorders. An example of this is the trait of perfectionism, especially in the restricting type of anorexia nervosa (Fairburn & Brownell, 2002). Obsessive and compulsive traits are also connected with anorexia nervosa symptoms (APA, 2013).
An example of this is obsessively thinking about and planning meals. Low self-esteem and difficulty coping with emotions are also common in those with anorexia nervosa (APA, 2013; Gual, P., et al, 2002; Peck & Lightsey, 2008). Individuals with anorexia nervosa also often experience difficulty expressing emotions.
There tends to be an increased risk for someone developing anorexia nervosa if they have an immediate family member who has been diagnosed with anorexia nervosa (APA, 2013). The exact reasons behind this possible genetic association are not known.However, researchers have hypothesized that genes may provide someone with a predisposition for developing anorexia nervosa, with the genes being expressed when triggered by risk factors. There have been studies that reveal abnormalities in the brain of individuals with anorexia nervosa, but it not known if this is a factor in anorexia nervosa development or a consequence (APA, 2013). Additional research is needed to clarify the genetic piece.
There have been some family dynamics that have an association with eating disorders (e.g., Tozza, Sullivan, Fear, McKenzie, & Bulik, 2003). Several of these dynamics include an emphasis on physical appearance, lack of emotional expression, chaos, and rigid or unclear boundaries.
However, the Academy For Eating Disorders (2010) released a position paper that refutes the idea that the family is a sole cause for someone developing an eating disorder. In fact, the authors stated that “family factors can play a role in the genesis and maintenance of eating disorders, current knowledge refutes that idea that they are either the exclusive or even primary mechanism that underlie risk” (Le Grange, Lock, Loeb, & Nicholls, 2010).
Therefore, it is important not to assume the family is to blame but to explore how the family system is impacted by an individual’s eating disorder or helps to maintain the eating disorder. Furthermore, family participation in treatment can be an important factor in recovery, especially for children and teenagers (LaGrange & Eisler, 2009).
Dieting has been associated with eating disorder development (Fairburn & Brownell, 2002). This could also include a reduction in food intake and subsequent weight loss due to an illness.
Ultimately it is important to remember that these risk factors are not necessarily causal in nature. Plenty of people have one or more risk factor and do not go on to develop anorexia nervosa or other eating disorder.
What About Suicide?
It should be noted that those who have been diagnosed with anorexia nervosa do have an increased risk for suicide (APA, 2013). One group of researchers found that suicide was the most common cause of death in their participants who were diagnosed with anorexia nervosa (Birmingham, Su, Hlysky, Goldner, and Gao, 2005). Therefore, a suicide risk assessment is needed. If suicidal thinking is present, it is important to seek professional help immediately. If someone is actively suicidal, call 9-1-1 immediately.
Treatment for Anorexia Nervosa
As you can see, anorexia nervosa can have devastating consequences on one’s life. Therefore, it is important to seek out professionals who are trained in the diagnosis and treatment of eating disorders.
Treatment for eating disorders involves a variety of professionals, such as a medical doctor, a registered dietitian, a therapist, and a psychiatrist. Again, make sure that the professional you work with has training and experience working with eating disorder diagnoses.Depending on the severity of anorexia nervosa (or any eating disorder), there are a variety of settings where treatment may be received. Which level of care is needed will be discussed during the initial evaluation and as is appropriate during the course of treatment.
The possible treatment settings include outpatient, intensive outpatient (IOP), partial hospitalization program (PHP), residential treatment, and inpatient hospitalization (considered the highest level of care). Again, your treating professional will recommend which approach is most needed based on a variety of factors (e.g., safety, medical condition, the severity of behaviors).
There are also a variety of therapy approaches that may be helpful for anorexia nervosa. Examples of types of therapy include dialectical behavioral therapy (DBT), cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), psychodynamic therapy, eye movement desensitization and reprocessing (EMDR) (for trauma), and interpersonal psychotherapy, and family therapy. You and your therapist will work together to find the approach that best suits your symptoms and goals.
It can be daunting to consider starting treatment. However, help is available and recovery is possible. Take the first step by reaching out for an initial evaluation and begin your road to recovery.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Brewerton, T.D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders, 15 (4), 285-304.
Birmingham, C.L., Su, J., Hlynsky, J.A, Goldner, E.M., & Gao, M. (2005). The mortality rate from anorexia nervosa. International Journal of Eating Disorders; 38: 143-146.
Fairburn, C.G., & Brownell, K.D. (2002). Eating Disorders and obesity, second edition: A comprehensive handbook. New York, NY: Gulford Press.
Gual, P., Pérez-Gaspar, M., Martínez-González, M. A., Lahortiga, F., Irala-Estévez, J.D, & Cervera-Enguix, S. (2002). Self-esteem, personality, and eating disorders: Baseline assessment of a prospective population-based cohort. International Journal of Eating Disorders, 31, 261–273.
Kong, S., & Bernstein, K. (2009). Childhood trauma as a predictor of eating psychopathology and its mediating variables in patients with eating disorders. Journal of Clinical Nursing, 18, 1897–1907.
Le grange, & Eisler, I. (2009). Family interventions in adolescent anorexia nervosa. Child and Adolescent Psychiatric Clinics of North America, 18, 159-173.
Le Grange D., Lock, J., Loeb, K., & Nicholls, D. (2010). Academy for eating disorders position paper: The role of the family in eating disorders. International Journal of Eating Disorders, 43 (1), 1-5.
National Eating Disorders Association (2018). Body Image. Retrieved from https://www.nationaleatingdisorders.org/body-image-0
Tozzi, F. Sullivan, P.F., Fear, J.L., McKenzie, J., & Buik, C.M. (2003). Causes and recovery in anorexia nervosa: The patient’s perspective. International Journal of Eating Disorders. 33(2), 143-154.