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Anorexia nervosa

Index > Conditions > Anorexia nervosa     Print
Also listed as: Eating disorders - anorexia

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment
Other Considerations
Supporting Research

Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behavior, severe self-induced weight loss, and psychiatric comorbidities. People with anorexia have an extreme fear of gaining weight, which causes them to try to maintain a weight far less than normal. They will do almost anything to avoid gaining weight, including starving themselves or exercising too much. People with anorexia have a distorted body image -- they think they are fat (even when they are extremely thin) and won't maintain a proper weight.

Anorexia is an emotional disorder that focuses on food, but it is actually an attempt to deal with perfectionism and a desire to gain control by strictly regulating food and weight. People with anorexia often feel that their self esteem is tied to how thin they are.

Anorexia is increasingly common, especially among young women in industrialized countries where cultural expectations encourage women to be thin. Fueled by popular fixations with thin and lean bodies, anorexia is also affecting a growing number of men, particularly athletes and those in the military.

Anorexia most commonly affects teens, as many as 3 in 100. Although anorexia seldom appears before puberty, when it does, associated mental conditions, such as depression and obsessive-compulsive behavior are usually more severe. Anorexia is often preceded by a traumatic event and is usually accompanied by other emotional problems. Anorexia is a life threatening condition that can result in death from starvation, heart failure, electrolyte imbalance, or suicide. For some people, anorexia is a chronic disease, one that lasts a lifetime. But treatment can help people with anorexia develop a healthier lifestyle and avoid anorexia's complications.

Signs and Symptoms

The primary sign of anorexia nervosa is severe weight loss. People with anorexia may try to lose weight by severely limiting how much food they eat. They may also exercise excessively. Some people may engage in binging and purging, similar to bulimia. They may vomit after eating or take laxatives. At the same time, the person may insist that they are overweight.

Physical Signs

  • Excessive weight loss
  • Scanty or absent menstrual periods
  • Thinning hair
  • Dry skin
  • Brittle nails
  • Cold or swollen hands and feet
  • Bloated or upset stomach
  • Downy hair covering the body
  • Low blood pressure
  • Fatigue
  • Abnormal heart rhythms
  • Osteoporosis

Psychological and Behavioral Signs

  • Distorted perception of self (insisting they are overweight when they are thin)
  • Being preoccupied with food
  • Refusing to eat
  • Inability to remember things
  • Refusing to acknowledge the seriousness of the illness
  • Obsessive-compulsive behavior
  • Depression

What To Watch For

  • Skipping meals or making excuses not to eat
  • Eating only a few foods
  • Refusing to eat in public
  • Planning and preparing elaborate meals for others but not eating
  • Constantly weighing themselves
  • Ritually cutting food into tiny pieces
  • Compulsive exercising

Causes

No one knows exactly what causes anorexia. Medical experts agree that several factors work together in a complex fashion to lead to the eating disorder. These may include:

  • Severe trauma or emotional stress (such as the death of a loved one or sexual abuse) during puberty or prepuberty.
  • Abnormalities in brain chemistry. Serotonin, a brain chemical that's involved in depression, may play a role
  • A cultural environment that puts a high value on thin or lean bodies.
  • A tendency toward perfectionism, fear of being ridiculed or humiliated, a desire to always be perceived as being "good." A belief that being perfect is necessary in order to be loved.
  • Family history of anorexia. About one fifth of people with anorexia have a relative with an eating disorder.

Risk Factors

  • Age and gender -- anorexia is most common in teens and young adult women.
  • Dieting
  • Weight gain
  • Unintentional weight loss
  • Puberty
  • Living in an industrialized country
  • Having depression, obsessive compulsive disorder (OCD) or other anxiety disorders -- OCD is present in up to two thirds of people with anorexia. OCD associated with an eating disorder is often accompanied by a compulsive ritual around food (such as cutting it into tiny pieces).
  • Participation in sports and professions that prize a lean body (such as dance, gymnastics, running, figure skating, horse racing, modeling, wrestling, acting)
  • Difficulty dealing with stress (pessimism, tendency to worry, refusal to confront difficult or negative issues)
  • History of sexual abuse or other traumatic event
  • Experiencing a big life change, such as moving or going to a new school

Diagnosis

People with anorexia may think they are in control of their disease and don't want any help. But if you or a loved one is experiencing signs of anorexia, it's important to seek help. If you are a parent who suspects your child has anorexia, take your child to see a doctor immediately. He/she will order several laboratory tests and perform a psychological evaluation. If your doctor suspects anorexia, he or she may use the SCOFF questionnaire, developed in Great Britain. A "yes" response to at least 2 of the following questions is a strong indicator of an eating disorder:

  • S: "Do you feel sick because you feel full?"
  • C: "Do you lose control over how much you eat?"
  • O:"Have you lost more than 13 pounds recently?"
  • F: "Do you believe that you are fat when others say that you are thin?"
  • F: "Does food and thoughts of food dominate your life?"

Lab tests may include:

  • Blood tests -- to look for signs of anemia, to check electrolytes, and to check liver and kidney function
  • Electrocardiogram -- to look for abnormal heart rhythms
  • Bone density test -- to check for osteoporosis

If your doctor makes a diagnosis of anorexia, you will likely work with a multidisciplinary team including a doctor, a psychologist or psychiatrist, and a registered dietitian.

Preventive Care

The most effective way to prevent anorexia is to develop healthy eating habits and a strong body image from an early age. Don't accept cultural values that place a premium on thin, perfect bodies. Make sure you and your children are educated about the life threatening nature of anorexia.

For people who have already developed anorexia, the primary goal is to avoid relapse.

  • Family and friends should be urged not to focus on the person's condition or on food or weight. Don't discuss anorexia at mealtimes, for example. Instead, devote mealtimes to social interaction and relaxation.
  • Watch for signs of relapse. Careful and frequent monitoring of weight and other physical signs by your doctor can catch problems early.
  • Cognitive behavioral therapy or other forms of psychotherapy can help the person develop coping skills and change unhealthy thought processes.
  • Family therapy can help with any problems in the home that may contribute to the person's anorexia.

Treatment

The most successful treatment is a combination of psychotherapy, family therapy, and medication. It is important for the person with anorexia to be actively involved in their treatment. Many times the person with anorexia doesn't think they need any treatment. Even if they know they need treatment, anorexia is a long term challenge that may last a lifetime. People remain vulnerable to relapse when going through stressful periods of their lives.

A combination of treatments can give the person the medical, psychological, and practical support they need. Cognitive behavioral therapy, along with antidepressants, can be an effective treatment for eating disorders. Complementary and alternative therapies may help with nutritional deficiencies.

If the person's life is in danger, hospitalization may be needed, particularly under the following circumstances:

  • Continuing weight loss, in spite of outpatient treatment
  • Body mass index (BMI) -- 30% below normal. The normal range is a BMI of 19 - 24. BMI is a measurement that takes into account a person's height and weight.
  • Irregular heart rhythm
  • Severe depression
  • Suicidal tendencies
  • Low potassium levels
  • Low blood pressure

Even after some weight gain, many people with anorexia remain quite thin and the risk of relapse is very high. Several social influences may make recovery difficult:

  • Friends or family who admire how thin the person is
  • Dance instructors or athletic coaches who put a premium on having a very lean body
  • Denial on the part of parents or other family members
  • The person's belief that extreme thinness is not only normal but also attractive, and that purging is the only way to avoid becoming overweight

Involving friends, family members, and others in the treatment may be helpful.

Lifestyle

Treating anorexia nervosa involves major lifestyle changes:

  • Establishing regular eating habits and a healthy diet
  • Sticking with your treatment and meal plans
  • Developing a support system and participating in a support group for help with stress and emotional issues
  • Ignoring the urge to weigh yourself or check your appearance constantly
  • Cutting back on exercise if obsessive exercise has been part of the disease. Once the person has gained weight, the doctor may set a controlled exercise program to improve overall health.

Medications

There are no medications specifically approved to treat anorexia. However, antidepressants are often prescribed to treat depression that may accompany anorexia. Your doctor may also prescribe drugs to help with OCD or anxiety. Medications, however, may not work alone and should be used in conjunction with a multidisciplinary approach that includes nutritional interventions and psychotherapy.

Selective serotonin reuptake inhibitors -- These antidepressants are sometimes prescribed for people with anorexia. Fluoxetine (Prozac) has been studied in people with anorexia and depression, with mixed results. In some early studies, it appeared to increase weight and improve mood over several months. But in another, it helped relieve symptoms of depression, but did not affect the anorexia itself.

Recent studies indicate that the use of Prozac and other antidepressants may cause children and teenagers to have suicidal thoughts. Children who are taking these drugs must be monitored very carefully for signs of potential suicidal behavior.

People with anorexia may not be getting the essential nutrients their bodies need. Your health care provider may prescribe potassium or iron supplements, or other supplements to make up for any deficiency. He/she may also prescribe cyproheptadine, an antihistamine that may stimulate appetite. In one study, using high doses of cyproheptadine hydrochloride decreased the number of days it took people with anorexia to gain an appropriate amount of weight.

Nutrition and Dietary Supplements

People with bulimia are more likely to have vitamin and mineral deficiencies, which can affect their health. Vitamin deficiencies can contribute to cognitive difficulties such as poor judgment or memory loss. Getting enough vitamins and minerals in your diet or through supplements can correct the problems.

Always tell your doctor about the herbs and supplements you are using or considering using, as some supplements may interfere with conventional treatments.

Following these nutritional tips may help overall health:

  • Avoid caffeine, alcohol, and tobacco.
  • Drink 6 - 8 glasses of filtered water daily.
  • Use quality protein sources -- such as meat and eggs, whey, and vegetable protein shakes -- as part of a balanced program aimed at gaining muscle mass and preventing wasting.
  • Avoid refined sugars, such as candy and soft drinks.

Your doctor may suggest addressing nutritional deficiencies with the following supplements:

  • A daily multivitamin, containing the antioxidant vitamins A, C, E, the B-vitamins and trace minerals, such as magnesium, calcium, zinc, phosphorus, copper, and selenium.
  • Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil 2 - 3 times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources; eat 2 servings of fish per week.
  • Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support. Coenzyme Q10 can potentially interfere with Coumadin (Warfarin) and other blood thinning medication.
  • 5-hydroxytryptophan (5-HTP), 50 mg 2 - 3 times daily, for mood stabilization. Talk with your health care provider if you are on prescription medications before taking 5-HTP. Do not take 5-HTP if you are taking antidepressants.
  • Creatine, 5 - 7 grams daily, when needed for muscle weakness and wasting.
  • Probiotic supplement (containing Lactobacillus acidophilus among other strains), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Refrigerate probiotic supplements for best results.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to diagnose your problem before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

  • Ashwagandha (Withania somniferum) standardized extract, 450 mg 1 - 2 times daily, for general health benefits and stress.Ashwagandha might cause sleepiness or drowsiness and therefore caution should be taken when combining with sedative medications.
  • Fenugreek (Trigonella foenum-graecum), 250 - 500 mg 2 - 3 times daily, to stimulate appetite. Fenugreek may not be safe for children. Fenugreek may lower blood sugar and therefore may interact with diabetes medications. Fenugreek may interact with medications that slow blood clotting (Anticoagulant / Antiplatelet drugs).
  • Milk thistle (Silybum marianum) seed standardized extract, 80 - 160 mg 2 - 3 times daily, for liver health. People with allergies to ragweed family of plants may have sensitivities to Milk thistle. Since Milk thistle works on the liver, there is potential that may affect medications that are metabolized through the liver, speak with your physician.
  • Catnip (Nepeta spp.), as a tea 2 - 3 times per day, to calm the nerves and soothe the digestive system. Women with heavy menstrual bleeding should avoid catnip. Catnip can interact with Lithium and certain sedative medications.

Homeopathy

No scientific literature supports the use of homeopathy for anorexia. However, an experienced homeopath will consider your individual case and may recommend treatments to address both your underlying condition and any current symptoms.

Mind-Body Medicine

Cognitive Behavioral Therapy

Cognitive behavioral therapy is one of the most effective therapies for anorexia. In cognitive behavioral therapy, the person learns to replace negative, unrealistic thoughts and beliefs with positive, realistic ones. The person is also encouraged to acknowledge their fears and to develop new, healthier ways of solving problems.

Family Therapy

In addition to individual therapy for someone who has anorexia, family therapy that involves parents and siblings is also recommended. Parents and other family members often have intense feelings of guilt and anxiety that they need to address. Family therapy is aimed, in part, at helping the parents or partner (in the case of an adult) understand the seriousness of this illness and the ways in which family patterns may contribute to it.

Hypnosis

Hypnosis may be helpful as part of an integrated treatment program for anorexia nervosa. Hypnosis may help the person strengthen both self confidence and the ability to cope. That may result in healthier eating, improved body image, and greater self esteem.

Biofeedback

Studies suggest that biofeedback may be helpful in reducing stress in people with anorexia.

Other Considerations

Pregnancy

Anorexia poses several potential problems for women who are pregnant or wish to become pregnant:

  • Difficulty getting pregnant and carrying a pregnancy to term because of higher rates of infertility and spontaneous abortion
  • Increased risk of low birth weight babies and birth defects
  • Malnourishment (particularly calcium deficiency) as the fetus grows
  • Increased risk of medical complications
  • Increased risk of relapse triggered by the stress of pregnancy or parenthood

Prognosis and Complications

Medical complications associated with anorexia include:

  • Irregular heartbeat and heart attack
  • Anemia, often related to lack of vitamin B12
  • Low potassium, calcium, magnesium, and phosphate levels
  • Increased cholesterol
  • Hormonal changes (can lead to absence of menstrual periods, infertility, bone loss, and stunted growth)
  • Osteoporosis
  • Seizures and numbness in hands and feet
  • Disorganized thinking
  • Death (suicide is responsible for 50% of fatalities associated with anorexia)

The outlook for people with anorexia is variable, with recovery often taking between 4 - 7 years. There is also a high chance of relapse even after recovery. Long term studies show that 50 - 70% of people recover from anorexia nervosa. However, 25% do not fully recover. Many, even after they are considered "cured," continue to show traits of anorexia, such as remaining very thin and striving for perfection. Anorexia is associated with high lifetime mortality from both natural and unnatural causes.

Supporting Research

Barabasz M. Efficacy of hypnotherapy in the treatment of eating disorders. Int J Clin Exp Hypn. 2007 Jul;55(3):318-35. Review.

Birmingham CL, Sidhu FK. Complementary and alternative medical treatments for anorexia nervosa: case report and review of the literature. Eat Weight Disord. 2007 Sep;12(3):e51-3. Review.

Cook-Darzens S, Doyen C, Mouren MC. Family therapy in the treatment of adolescent anorexia nervosa: current research evidence and its therapeutic implications. Eat Weight Disord. 2008;13(4):157-70.

Escolar DM, Buyse G, Henricson E, et al. CINRG randomized controlled trial of creatine and glutamine in Duchenne muscular dystrophy. Ann Neurol. 2005;58(1):151-5.

Espindola CR, Blay SL. Anorexia nervosa treatment from the patient perspective: a metasynthesis of qualitative studies. Ann Clin Psychiatry. 2009;21(1):38-48.

Ferri: Ferri's Clinical Advisor, 2011, 1st ed. Anorexia Nervosa. St. Louis, MO: Mosby. 2010.

Field T. Massage therapy effects. Am Psychol. 1998;53:1270-1281.

Holman RT, Adams CE, Nelson RA, et al. Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids. J Nutr 1995;125:901-907.

Kleifield EI, Wagner S, Halmi KA. Cognitive-behavioral treatment of anorexia nervosa. Psychiatric Clin N Am. 1996;19:715-737.

LaValle JB, Krinsky DL, Hawkins EB, et al. Natural Therapeutics Pocket Guide. Hudson, OH:LexiComp; 2000: 387-388.

Loeb KL, Walsh BT, Lock J, le Grange D, Jones J, Marcus S, Weaver J, Dobrow I. Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: evidence of successful dissemination. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):792-800.

Lozano GA. Obesity with sexually selected anorexia nervosa. Med Hypotheses. 2008;71(6):933-40.

McNulty. Prevalence and contributing factors of eating disorder behaviors in active duty Navy men. Mil Med. 1997;162(11):753-758.

Moyano D, Sierra C, Brandi N, et al. Antioxidant status in anorexia nervosa. Int J Eating Disord. 1999;25:99-103.

Papadopoulos FC, Ekbom A, Brandt L, Ekselius L. Excess mortality, causes of death and prognostic factors in anorexia nervosa. Br J Psychiatry. 2009;194(1):10-7.

Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Ped Int. 2000;42:76-81.

Rock CL, Vasantharajan S. Vitamin status of eating disorder patients: Relationship to clinical indices and effect of treatment. Int J Eating Disord. 1995;18:257-262.

Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin. 2001;17(1):239-47.

Shay NF, Manigan HF. Neurobiology of zinc-influenced eating behavior. J Nutr. 2000;130:1493S-1499S.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs. 2000;9(9):2103-19.

Wheatland R. Alternative treatment considerations in anorexia nervosa. Med Hypotheses. 2002;59(6):710-5.

Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. Am Fam Physician. 2008 Jan 15;77(2):187-95.

Wiseman CV, Harris WA, Halmi KA. Eating disorders. Medical Clin N Am. 1998;82:145-159.

Wolfe BE, Metzger ED, Jimerson DC. Research update on serotonin function in bulimia nervosa and anorexia nervosa. Psychopharmacol Bull. 1997;33:345-354.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-96.

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Review Date: 12/11/2010
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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