Anorexia Nervosa: Symptoms, Causes & Treatment Guide

What Is Anorexia Nervosa?

Anorexia nervosa is a serious eating disorder characterized by restriction of food intake leading to significantly low body weight, intense fear of gaining weight, and a distorted perception of body weight or shape. It has the highest mortality rate of any psychiatric disorder, affecting approximately 0.3-0.4% of young women and 0.1% of young men.

Anorexia nervosa is far more than simply wanting to lose weight or being picky about food. It is a complex mental health condition that involves an intense preoccupation with food, body weight, and body shape that significantly interferes with a person's health, daily functioning, and quality of life. The word "anorexia" literally means "loss of appetite," but this is actually a misnomer - people with anorexia typically feel hunger but actively suppress it due to a powerful fear of weight gain.

The disorder typically begins during adolescence or young adulthood, with peak onset occurring between ages 14 and 18. However, anorexia can develop at any age, and cases in children as young as 7 and adults over 40 are documented. While historically considered a condition primarily affecting young women, research now shows that eating disorders affect people of all genders, ages, races, ethnicities, body shapes, weights, sexual orientations, and socioeconomic backgrounds.

What makes anorexia particularly challenging to treat is the ego-syntonic nature of the illness - meaning that people with anorexia often do not see their behaviors as problematic. Instead, they may view their restriction and weight loss as achievements or signs of self-control. This disconnect between how the person perceives themselves and the reality visible to others is a hallmark of the condition and one of the biggest barriers to seeking help.

Two Types of Anorexia Nervosa

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes two subtypes of anorexia nervosa, each with distinct behavioral patterns:

• Restricting type: Weight loss is achieved primarily through dieting, fasting, and/or excessive exercise. The person does not regularly engage in binge eating or purging behaviors such as self-induced vomiting or misuse of laxatives. This is the most common subtype and often considered the "classic" presentation of anorexia.
• Binge-eating/purging type: The person restricts food intake but also periodically engages in binge eating and/or purging behaviors. This subtype carries additional health risks related to purging, including electrolyte imbalances, dental erosion, and esophageal tears. It is important not to confuse this with bulimia nervosa - in anorexia binge-eating/purging type, the person maintains a significantly low body weight.

It is worth noting that people can transition between subtypes over time, and the boundaries between eating disorder diagnoses can be fluid. What remains consistent is the core feature of anorexia: the relentless pursuit of thinness and fear of weight gain.

The Distorted Body Image

One of the most striking and difficult-to-understand aspects of anorexia is body image disturbance. People with anorexia typically perceive their bodies as much larger than they actually are. When looking in a mirror, they may see a person who appears overweight, even when they are dangerously underweight. This is not a matter of lying or seeking attention - the distortion is real and pervasive.

This body dysmorphia extends beyond visual perception. People with anorexia often feel fat, regardless of objective measures. They may interpret normal bodily sensations like fullness after eating as evidence of gaining weight. Their self-worth becomes entirely dependent on their weight and ability to control their eating, creating a vicious cycle where any weight gain, however small, triggers intense distress and more extreme restriction.

The Need for Control

Many people with anorexia describe feeling that their control over food and weight is one of the only things in life they can truly control. This sense of mastery can feel empowering, especially for individuals who feel powerless in other areas of their lives. In the short term, restriction may reduce anxiety and provide a sense of achievement. However, this relief is temporary and comes at a devastating cost.

As the illness progresses, what initially felt like control becomes compulsion. The rules around eating become increasingly rigid and all-consuming. Activities that once brought joy are abandoned in favor of exercise routines. Social connections deteriorate as meals with others become impossible. Paradoxically, the pursuit of control leads to being completely controlled by the eating disorder.

What Are the Symptoms of Anorexia Nervosa?

Symptoms of anorexia nervosa include dramatic weight loss, intense fear of gaining weight, distorted body image, restrictive eating patterns, excessive exercise, preoccupation with food and calories, withdrawal from social activities, and denial of hunger or the seriousness of low weight. Physical signs include feeling cold, fatigue, dizziness, hair loss, and loss of menstruation.

Recognizing the signs of anorexia nervosa is crucial for early intervention, which significantly improves treatment outcomes. The symptoms of anorexia can be categorized into behavioral, emotional, and physical manifestations. It is important to understand that not everyone with anorexia will display all of these symptoms, and the severity can vary widely between individuals.

Because people with anorexia often go to great lengths to hide their behaviors and may not recognize that they have a problem, it is often family members, friends, or teachers who first notice warning signs. Being aware of these signs can help loved ones encourage the person to seek help before the illness becomes more entrenched.

Behavioral Warning Signs

The behavioral changes in anorexia nervosa often center around food, eating, and body shape. These behaviors may develop gradually and become more pronounced over time:

• Dramatic changes in eating habits: Severely limiting food intake, skipping meals, making excuses to avoid eating, creating rigid rules about what and when to eat
• Food rituals: Cutting food into tiny pieces, moving food around the plate, eating foods in a specific order, eating extremely slowly
• Preoccupation with food: Spending excessive time thinking about food, reading recipes, cooking elaborate meals for others without eating, collecting recipes or food images
• Excessive exercise: Compulsive, rigid exercise routines that take priority over other activities, exercising despite illness or injury, extreme distress if unable to exercise
• Frequent body checking: Repeatedly weighing oneself, measuring body parts, checking appearance in mirrors, pinching skin to measure fat
• Wearing baggy clothing: Dressing in loose or layered clothing to hide weight loss or stay warm
• Social withdrawal: Avoiding social situations involving food, pulling away from friends and family, loss of interest in previously enjoyed activities
• Denial: Refusing to acknowledge hunger, downplaying the seriousness of weight loss, becoming defensive when concerns are raised

Psychological and Emotional Symptoms

The psychological impact of anorexia extends far beyond concerns about weight and shape. The malnutrition itself affects brain function, intensifying emotional symptoms:

• Intense fear of weight gain: Terror at the thought of gaining even a small amount of weight, feeling fat despite being underweight
• Distorted body image: Seeing oneself as overweight despite clear evidence of being underweight, inability to accurately assess one's body size
• Perfectionism: Setting impossibly high standards, harsh self-criticism, all-or-nothing thinking
• Depression and anxiety: Persistent sad mood, feelings of worthlessness, excessive worry, irritability
• Obsessive thoughts: Constant preoccupation with food, calories, weight, and body shape that interferes with concentration and daily activities
• Emotional numbness: Difficulty identifying and expressing emotions, feeling detached from feelings
• Low self-esteem: Self-worth almost entirely dependent on weight and ability to control eating
• Suicidal thoughts: In severe cases, thoughts of self-harm or suicide. If you or someone you know is having suicidal thoughts, please seek immediate help.

What Happens to the Body?

The physical effects of anorexia nervosa result from malnutrition and the body's attempts to conserve energy when deprived of adequate nutrition. These effects can range from mild to life-threatening and can affect virtually every organ system in the body:

The longer anorexia persists and the more severe the malnutrition, the greater the risk of permanent damage. However, it is important to emphasize that with appropriate treatment and weight restoration, many of these physical effects can be reversed or significantly improved.

Signs of Medical Emergency

Certain symptoms indicate a medical emergency requiring immediate attention:

• Fainting or loss of consciousness
• Chest pain or rapid, irregular heartbeat
• Severe abdominal pain
• Confusion or difficulty thinking clearly
• Extreme weakness or difficulty standing
• Suicidal thoughts or self-harm

What Causes Anorexia Nervosa?

Anorexia nervosa is caused by a complex interaction of genetic, psychological, and environmental factors. Genetic factors account for 50-80% of the risk. Psychological factors include perfectionism, anxiety, and difficulty managing emotions. Environmental triggers include cultural pressure for thinness, trauma, and stressful life events. Anorexia is not caused by vanity or a desire for attention.

Understanding the causes of anorexia nervosa requires moving beyond simplistic explanations. This is not a disorder caused by dieting gone too far, vain attempts to look like fashion models, or attention-seeking behavior. Anorexia nervosa is a serious biopsychosocial illness with roots in genetics, brain chemistry, personality traits, psychological factors, and environmental influences.

Research over the past two decades has transformed our understanding of eating disorders, revealing them to be complex brain-based illnesses with significant biological components. This understanding is crucial not only for developing better treatments but also for reducing the stigma and blame that people with anorexia and their families often experience.

Genetic and Biological Factors

Twin studies have consistently shown that genetics play a substantial role in anorexia nervosa, with heritability estimates ranging from 50% to 80%. This means that genetic factors contribute significantly to whether someone develops the disorder. Having a close relative with anorexia increases the risk 10-fold compared to the general population.

Specific genetic variations have been identified that affect:

• Serotonin pathways: Serotonin regulates mood, appetite, and impulse control. Abnormalities in serotonin function may contribute to anxiety, perfectionism, and restricted eating
• Reward circuitry: People with anorexia may process hunger and satiety signals differently, finding starvation less aversive than others would
• Metabolic factors: Genetic variations affecting metabolism may interact with dietary restriction to perpetuate the illness
• Anxiety and obsessive-compulsive traits: Many of the genes associated with anorexia overlap with those for anxiety and OCD

It is important to understand that having genetic risk factors does not mean someone will definitely develop anorexia. Genes create vulnerability, but environmental factors typically trigger the onset of the illness.

Psychological Factors

Certain personality traits and psychological characteristics are commonly seen in people who develop anorexia nervosa. These traits often precede the eating disorder and may be part of the underlying vulnerability:

• Perfectionism: Setting extremely high standards and being harshly self-critical when these standards are not met
• Anxiety: Baseline anxiety that predates the eating disorder, often including social anxiety or generalized anxiety
• Difficulty with emotional regulation: Struggling to identify, express, and manage emotions in healthy ways
• Low self-esteem: Poor sense of self-worth that becomes tied to weight and eating control
• Obsessive-compulsive traits: Rigidity, need for control, difficulty with uncertainty
• Harm avoidance: Tendency to avoid risks, worry about future outcomes, and suppress impulses

Environmental and Social Factors

Environmental factors can trigger anorexia in individuals who are genetically and psychologically vulnerable. These triggers often interact with existing vulnerability to precipitate the onset of the disorder:

• Cultural emphasis on thinness: Living in cultures that idealize thin bodies and stigmatize larger bodies increases risk
• Trauma: Physical, sexual, or emotional abuse significantly increases risk for all eating disorders
• Bullying or teasing: Weight-related teasing, especially during childhood or adolescence
• Dieting: Starting a diet, especially during adolescence, can trigger eating disorder development in vulnerable individuals
• Stressful life transitions: Starting a new school, going to university, relationship changes, job loss
• Activities emphasizing weight: Sports like gymnastics, ballet, wrestling, or running that emphasize leanness
• Social media: Exposure to idealized images and diet culture content can reinforce eating disorder behaviors

When and Where Should You Seek Help?

Seek professional help as soon as you or someone you know shows signs of anorexia. Early intervention dramatically improves recovery outcomes. Contact your primary care doctor, a mental health professional, or an eating disorder specialist. Seek emergency care immediately for fainting, chest pain, severe weakness, or suicidal thoughts.

One of the most challenging aspects of anorexia nervosa is that people with the condition often do not believe they are sick or need help. The disorder itself impairs insight and can make the person resistant to treatment. This means that family members, friends, or other concerned individuals often play a crucial role in recognizing the problem and encouraging the person to seek help.

The importance of early intervention cannot be overstated. Research consistently shows that the earlier treatment begins, the better the outcomes. Anorexia that is treated within the first three years of onset has significantly higher recovery rates than long-standing illness. Waiting to seek help allows the disorder to become more entrenched and more difficult to treat.

When to Seek Help

If you recognize several of the following signs in yourself or someone you care about, it is time to seek professional help:

• Significant weight loss or failure to gain weight as expected during growth
• Preoccupation with food, calories, weight, or body shape that interferes with daily life
• Refusal to eat certain foods, progressing to restriction of entire food groups
• Making excuses to avoid eating or avoiding social situations involving food
• Excessive exercise that takes priority over other activities
• Comments about feeling fat or overweight despite being thin
• Withdrawal from friends, family, and activities once enjoyed
• Loss of menstrual periods (in females)
• Feeling cold all the time, hair loss, fatigue, or dizziness

Do not wait until the person "looks sick enough" or reaches a certain weight. Anorexia nervosa can cause serious medical complications and be life-threatening at any weight. Someone can be medically unstable while still appearing normal weight.

Where to Seek Help

Several types of healthcare professionals can help with the initial assessment and treatment of anorexia nervosa:

• Primary care physician: A good starting point for initial assessment, medical monitoring, and referrals to specialists
• Psychiatrist: A medical doctor specializing in mental health who can diagnose eating disorders and prescribe medications if needed
• Psychologist or therapist: Mental health professionals who provide psychotherapy and behavioral interventions
• Eating disorder specialist: Professionals with specific training and experience in treating eating disorders
• Registered dietitian: Nutrition professionals who can help with meal planning and nutritional rehabilitation

Many areas have specialized eating disorder treatment centers or clinics that offer comprehensive care. These centers bring together medical, psychiatric, psychological, and nutritional expertise in one setting.

Approaching Someone You Are Concerned About

If you are worried about a friend or family member, having a conversation about your concerns can feel intimidating. Here are some guidelines for approaching the topic:

• Choose the right time and place: Have the conversation privately, when you will not be interrupted, and when neither of you is upset or rushed
• Use "I" statements: Express your own observations and feelings rather than accusing. For example: "I've noticed you seem tired lately and I'm worried about you"
• Be specific but non-judgmental: Mention specific behaviors you have observed without labeling them as good or bad
• Avoid comments about weight or appearance: Focus on health and wellbeing rather than how the person looks
• Be prepared for denial or anger: The person may react defensively. Stay calm and let them know you care
• Offer support: Let them know you are there for them and offer to help them find professional support

How Is Anorexia Nervosa Diagnosed?

Anorexia nervosa is diagnosed through a comprehensive assessment including physical examination, laboratory tests, and psychological evaluation. The DSM-5 criteria require restriction of food intake leading to significantly low body weight, intense fear of gaining weight, and disturbance in how body weight or shape is experienced. Ruling out other medical conditions is also important.

Accurate diagnosis of anorexia nervosa requires a thorough evaluation by healthcare professionals. Because anorexia affects both physical and mental health, assessment typically involves both medical and psychological components. The evaluation serves multiple purposes: confirming the diagnosis, ruling out other conditions that might explain symptoms, assessing the severity of the illness, and identifying any medical complications that need immediate attention.

Physical Examination and Medical Tests

The physical assessment helps determine the medical impact of the eating disorder and identify any complications requiring treatment:

• Vital signs: Heart rate, blood pressure (lying down and standing), temperature, and respiratory rate
• Height and weight: Calculation of Body Mass Index (BMI) and assessment of weight history
• Physical examination: Assessment of heart, lungs, abdomen, skin, hair, and other systems
• Blood tests: Complete blood count, electrolytes (potassium, sodium, chloride), liver function, kidney function, thyroid function, blood glucose
• ECG (electrocardiogram): To check heart rhythm and detect abnormalities caused by electrolyte imbalances
• Bone density scan: To assess for osteoporosis, especially in cases of prolonged illness

Psychological Evaluation

The psychological assessment explores eating behaviors, thoughts about food and body, mood, and other mental health concerns:

• Diagnostic interviews: Structured or semi-structured interviews to assess eating behaviors, weight history, and psychological symptoms
• Standardized questionnaires: Validated tools that measure eating disorder symptoms, depression, anxiety, and other psychological factors
• Assessment of co-occurring conditions: Screening for depression, anxiety, OCD, PTSD, and other conditions that commonly occur with eating disorders
• Risk assessment: Evaluation of suicidal thoughts, self-harm behaviors, and other safety concerns

Diagnostic Criteria (DSM-5)

To receive a diagnosis of anorexia nervosa according to the DSM-5, a person must meet all of the following criteria:

1. Restriction of energy intake: Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health
2. Intense fear of gaining weight: Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight
3. Body image disturbance: Disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

The severity of anorexia is then specified based on BMI (for adults) or BMI percentile (for children and adolescents), ranging from mild to extreme.

What Treatment Is Available for Anorexia Nervosa?

Treatment for anorexia nervosa involves a multidisciplinary approach combining psychotherapy (especially CBT-E and Family-Based Treatment), nutritional rehabilitation, medical monitoring, and sometimes medication. Treatment may be outpatient, day program, or inpatient depending on severity. Recovery typically requires 6-12 months of active treatment, with 50-70% achieving full recovery.

Effective treatment for anorexia nervosa requires addressing both the psychological and physical aspects of the illness. Because anorexia affects the mind, body, and social functioning, treatment typically involves a team of professionals working together. The treatment goals are to restore healthy weight, address the psychological factors driving the eating disorder, and prevent relapse.

The intensity and setting of treatment depends on the severity of the illness. Options range from outpatient treatment (living at home and attending regular appointments) to partial hospitalization or day programs (intensive treatment during the day while sleeping at home) to inpatient hospitalization (24-hour medical and psychiatric care) or residential treatment (living in a treatment facility).

Psychotherapy

Psychotherapy is a cornerstone of anorexia treatment. Several evidence-based approaches have been shown to be effective:

• Family-Based Treatment (FBT): Also known as the Maudsley Approach, FBT is the gold standard treatment for adolescents with anorexia. Parents take an active role in refeeding their child, gradually returning control over eating as the young person recovers. FBT has the strongest evidence base for adolescent anorexia.
• Enhanced Cognitive Behavioral Therapy (CBT-E): A specialized form of CBT designed specifically for eating disorders. CBT-E addresses the thoughts, feelings, and behaviors that maintain the eating disorder, including overvaluation of weight and shape, dietary restriction, and compensatory behaviors.
• Specialist Supportive Clinical Management (SSCM): Combines nutritional management with supportive psychotherapy, focusing on normalizing eating and addressing symptoms.
• Interpersonal Psychotherapy (IPT): Focuses on improving interpersonal relationships and communication, which can help address some of the underlying factors contributing to the eating disorder.
• Dialectical Behavior Therapy (DBT): May be helpful for individuals who also struggle with emotional regulation, self-harm, or borderline personality traits.

Nutritional Rehabilitation

Restoring adequate nutrition and achieving a healthy weight is essential for recovery. Malnutrition affects brain function and makes it difficult to engage effectively in psychological treatment. Nutritional rehabilitation typically involves:

• Working with a registered dietitian to develop a structured meal plan
• Gradual increase in caloric intake to promote weight gain
• Education about normal eating and nutritional needs
• Support during meals to reduce anxiety and prevent restriction
• Addressing food fears and rules through exposure and practice

Medical Monitoring

Ongoing medical monitoring is important throughout treatment to track physical recovery and detect any complications. This includes regular measurements of weight, vital signs, and laboratory tests. The frequency of monitoring depends on the severity of the illness and setting of treatment.

Medication

There is no medication that treats anorexia nervosa itself. However, medications may be used to address co-occurring conditions:

• Antidepressants: May be prescribed if depression or anxiety persists after weight restoration. SSRIs are commonly used but are generally more effective once weight has been restored.
• Olanzapine: An atypical antipsychotic that has shown some benefit for weight restoration and reducing anxiety about eating in some studies.
• Other medications: Treatment of specific complications such as osteoporosis may involve additional medications.

It is important to note that medication alone is not effective for anorexia and should always be combined with psychotherapy and nutritional treatment.

Duration of Treatment

Recovery from anorexia nervosa takes time. Active treatment typically lasts at least 6-12 months, and many people benefit from longer-term follow-up and support. Treatment duration depends on factors including the duration of illness before treatment, severity, response to treatment, and presence of co-occurring conditions.

It is normal for recovery to have ups and downs. Setbacks do not mean treatment has failed - they are opportunities to learn and strengthen recovery skills. Many treatment programs offer stepped care, adjusting the intensity of treatment as the person progresses.

Can People Fully Recover from Anorexia?

Yes, full recovery from anorexia nervosa is possible. Research shows that 50-70% of people achieve full recovery with appropriate treatment. Early intervention significantly improves outcomes. Recovery involves restoring healthy weight, normalizing eating, and addressing underlying psychological factors. With persistence and support, even people with long-standing illness can recover.

One of the most important messages for anyone affected by anorexia nervosa is that recovery is possible. It may feel impossible when you are in the depths of the illness, but many people have recovered from even severe and long-standing anorexia to live full, healthy lives free from eating disorder symptoms.

Research on long-term outcomes shows that approximately half to two-thirds of people with anorexia achieve full recovery. "Full recovery" means not just restoring weight but also normalizing eating behaviors, reducing preoccupation with weight and shape, and no longer meeting diagnostic criteria for an eating disorder. An additional 20-30% show significant improvement but may continue to have some symptoms. Unfortunately, a portion of people develop chronic illness or die from medical complications or suicide.

What Predicts Better Outcomes?

Several factors are associated with better prognosis in anorexia nervosa:

• Early intervention: The shorter the duration of illness before treatment, the better the outcomes. Treatment within the first three years of onset is associated with significantly higher recovery rates.
• Younger age at onset: Adolescents generally have better outcomes than adults, particularly with family-based treatment.
• Less severe symptoms: Higher initial weight, fewer psychiatric comorbidities, and absence of binge-purge behaviors are associated with better prognosis.
• Strong support system: Having family or other support during treatment improves outcomes.
• Engagement in treatment: Active participation in therapy and willingness to make changes predicts better outcomes.

Preventing Relapse

Even after achieving recovery, vigilance is important as relapse can occur, particularly during stressful periods. Strategies to maintain recovery include:

• Continuing to practice skills learned in treatment
• Maintaining regular eating patterns
• Managing stress through healthy coping strategies
• Avoiding triggers when possible
• Staying connected with treatment providers for maintenance appointments
• Reaching out for help promptly if symptoms recur

Pregnancy and Anorexia Nervosa

Anorexia nervosa during or before pregnancy poses significant risks to both mother and baby, including increased risk of miscarriage, preterm birth, low birth weight, and postpartum depression. Women with a history of anorexia should inform their healthcare providers during pregnancy planning. With proper monitoring and support, healthy pregnancies are possible.

Pregnancy can be a challenging time for women with a current or past history of anorexia nervosa. The physical changes of pregnancy - weight gain, changing body shape, and altered eating patterns - can trigger or exacerbate eating disorder symptoms even in women who have been recovered for years. At the same time, the nutritional demands of pregnancy make it essential that the mother receives adequate nutrition.

If you have a history of anorexia and are planning to become pregnant, it is important to discuss this with your healthcare provider. Ideally, recovery should be well-established before pregnancy, but even women who are still struggling can have healthy pregnancies with appropriate support and monitoring.

Close collaboration between maternity care providers and eating disorder specialists is essential for women with eating disorders. More frequent prenatal appointments, nutritional counseling, and mental health support can help ensure the best outcomes for both mother and baby.

How Can You Support Someone with Anorexia?

Supporting a loved one with anorexia nervosa can be emotionally challenging, but your support can make a significant difference in their recovery. Here are evidence-based strategies for being helpful:

• Educate yourself: Learn about anorexia nervosa to better understand what your loved one is experiencing. Understanding that this is an illness, not a choice, helps you respond with compassion rather than frustration.
• Avoid blame: Neither the person with anorexia nor their family caused the illness. Blame is counterproductive and harmful.
• Be patient: Recovery takes time and is rarely a straight path. Expect setbacks and try not to lose hope.
• Focus on health, not weight: Avoid commenting on appearance or weight. Instead, express concern about wellbeing and health.
• Avoid food battles: Leave meal management to the treatment team. Trying to force someone to eat typically backfires.
• Model normal eating: Eat regular, balanced meals yourself. Avoid diet talk or negative body comments.
• Encourage professional help: Support your loved one in seeking and continuing treatment.
• Take care of yourself: Supporting someone with an eating disorder is stressful. Seek your own support through family groups, therapy, or trusted friends.