Anorexia Nervosa: What it is, symptoms, causes and treatment
Anorexia nervosa is currently one of the mental disorders with the highest mortality rates. 90% of anorexia nervosa cases happen in women and its incidence has doubled in the last 10-20 years. But the question is what is “anorexia nervosa”? Can anorexia nervosa lead to death? Are there different types of anorexia nervosa? What are the signs and symptoms of anorexia nervosa? What is the cause of anorexia nervosa? What is the difference with bulimia? Is it treatable? In this article, you will find all these answers and more about anorexia nervosa.
Anorexia Nervosa: Concept and Definition
Morton introduced the concept of “anorexia” in 1689 to define a picture whose main feature is low weight. Currently, anorexia nervosa appears as a disorder of eating behavior in mental health diagnostic manuals. It is an emotional disorder characterized by an obsessive desire to lose weight by refusing to eat.
In anorexia nervosa, there is a refusal to maintain body weight equal to or above the minimum value considering age and height. The BMI normally does not exceed 17.5 and the weight is less than 85% of the expected. People with anorexia nervosa fear fatness or flaccidity, so it is imperative to remain below a maximum weight limit.
Weight loss is intentionally caused by the person. This is done by avoiding “fattening foods”, causing vomiting, intestinal purges, drinking diuretics or excessive exercise. In adolescence, particularly in girls, there may be amenorrhea and in boys less sexual potency.
Types of Anorexia Nervosa
There are two subtypes of anorexia nervosa: restrictive and binge eating/purgative.
The main difference is whether or not binge eating or purging (such as inducing vomiting or excessive use of laxatives, diuretics or enemas) has occurred.
Binge eating or purging is regularly done in the latter subtype while it is absent in restrictive anorexia nervosa. In restrictive anorexia nervosa, for example, people resort to extreme physical exercise, diets or long fasting.
Pawlowski and Masiak conducted a sociodemographic study to discover the differences between the two types of anorexia. They found that people with purgative anorexia nervosa were often victims of physical or sexual abuse, more than people with restrictive anorexia nervosa. Girls affected by restrictive anorexia nervosa also have a better relationship with their family, especially with their mother.
In both forms of anorexia nervosa, a high percentage of alcohol abuse by the father was found. Just as in restrictive anorexia nervosa, it is common for families to suffer from mental disorders.
Signs and Symptoms of Anorexia Nervosa
Diagnostic criteria for anorexia nervosa according to DSM 5
A. Restriction of energy intake relative to conventional intake, leading to a significantly low body weight (below normal or expected) relative to age, sex, developmental trajectory and physical health.
B. Intense fear of gaining weight and becoming an obese or persistent behavior that interferes with weight gain, despite being significantly underweight.
C. Alteration in the way one’s own body weight is perceived, exaggeration of weight or body shape on self-assessment, or lack of recognition on the severity of the weight loss.
The subtype is specified according to time criteria:
- Restrictive: In the last 3 months there have been no recurrent binge eating episodes or purgative behaviors.
- Binge eating/purging: Recurrent binge eating or purgative behavior has happened in the past 3 months.
Other symptoms, other than weight loss, may appear:
Psychiatric: Thought process and cognitive skills may feel slower and tasks of greater cognitive demands may seem even more strenuous. Memory may be affected as well as attention, and concentration levels. Distortions and biases appear in relation to body image and weight.
Skin: Subcutaneous fat loss, the skin becomes drier and the nails more fragile. Hair loss and intolerance to cold temperatures are common.
Cardiac: The myocardial contraction is altered. Hypotension and bradycardia are common making the risk of sudden death is increased.
Endocrine: Hormones are continuously altered. In women, menstrual cycles are altered and may even disappear (amenorrhea). There might be breast tissue atrophy.
Gastric: Intestinal motility is altered, bowel emptying slows down and constipation is common.
Others: Sleep and sexual appetite are altered, resulting in insomnia and lack of appetite.
Hospital admission criteria for anorexia nervosa
In the case of Anorexia nervosa, there are two types of criteria: medical and psychological.
The medical symptoms that need to be present to be admitted into the hospital are BMI below 14 or rapid weight loss (more than 20% in 6 months), fainting, hypoglycemia or electrolytic imbalance.
The psychological symptoms that need to be present are a high suicidal risk, conflicting family situation, extreme social isolation or failure of previous outpatient treatment.
Causes of Anorexia Nervosa
There isn’t just one cause of anorexia nervosa, but different factors that relate to each other and contribute to the establishment and maintenance of this eating disorder.
Predisposing factors for anorexia nervosa include genetics, age (13-21), mood disorders, introversion, obesity, medium/high social status, and family members with mood or eating disorders. For example, it has been seen how there is a higher prevalence of these disorders in daughters whose mothers have also had an eating disorder. The values and coping strategies transmitted through education are said to facilitate eating disorders.
Body changes in adolescence, separations, and losses, parent divorce, sexual contact, rapid weight gain, body critiques, trauma, increased physical activity and significant life events have been identified as possible precipitating factors.
For example, if we add to the typical insecurities in adolescence, the insistence of peer pressure plus society’s high standards regarding physical appearance it becomes easy to develop eating disorders.
Once the disorder is established, maintenance factors for anorexia nervosa make it easier for the disorder to last. The person has already established diet rituals, exercise, guilt for their noncompliance and satisfaction with weight control.
Anorexia Nervosa vs Bulimia
Both anorexia nervosa and bulimia nervosa are more common in women. In both disorders, there are negative emotions and body image distortions, restrictive diets, anxiety after eating, and physical exercise.
Unlike anorexia nervosa, bulimia is not characterized for being low in weight. The prevalence is higher and its course is chronic. The mortality rate is low and the onset age is later. The severity of the disorder, impulsivity as a personality trait, substance abuse, self-harm behaviors, and alcoholism in the family may worsen these eating disorders.
The following table shows the most important differences and similarities between anorexia nervosa and bulimia nervosa.
|ANOREXIA NERVOSA||BULIMIA NERVOSA|
|Restrictive AN||Purgative AN||Purgative BN||Non purgative BN|
|Age||13-21 years old||18-25 years old|
|A relation between emotion and binge eating||YES|
|Negative attitude toward image||YES|
|Anxiety after eating||NO||YES|
|Physical Exercise||YES||YES||YES OR NO||YES|
Diagnose Anorexia Nervosa
A multidisciplinary intervention (doctor, psychologist, nutritionist, etc.) is essential in order to diagnose anorexia nervosa. A medical evaluation is essential and prior to any other evaluation and/or intervention.
The examination assesses body weight, eating patterns, cognition, and other psychopathology or disorders.
Among the standardized tests to diagnose AN we found: EAT-40 (Eating Attitudes Test) by Garner and Garfinkel (1979), EAT-20 (in screening format), EDI (Eating Disorder Inventory) by Garner, Olmsted and Polivy (1983), EDI-2 (Garner, 1991); ABOS (Anorexic Behavioral Observation Scale for parents and spouse); BSQ (Body Shape Questionnaire), BAT (Body Attitudes Test), BSRQ (Body-Self Relations Questionnaire) and FES (Family Climate Scale).
Comorbidity and Anorexia Nervosa
Eating disorders are mainly associated with personality disorders, substance-related disorders (stimulants may be used to reduce appetite), anxiety disorders, mood disorders, obsessive-compulsive disorder, and impulse control disorder.
Specifically, AN has been linked to the C cluster of personality disorders, especially obsessive, avoidant and dependent disorders.
The restrictive subtype has characteristics of obsessive-compulsive disorders such as perfectionism and rigidity. These people, have a high sense of hyper-responsibility and carry very strict rituals with nutrition, sports, and weight control, which increase with feelings of guilt and inefficiency. Negative self-image, low self-esteem, and distortions in thinking negatively affect mood leading to depression. Anxiety can also derive in phobia towards certain foods, social phobia, etc.
The binge eating/purge subtype is most common when there is a family history of obesity, pre-disorder overweight, increased emotional lability, or addiction. They are impulsive people who lose their self-control during binge eating.
Course and Prognosis of Anorexia Nervosa
The course and prognosis of the disorder are variable, although long-term mortality is 10%. The most common causes of death in anorexia nervosa are starvation, suicide, or electrolyte imbalance. Poor prognostic factors include the duration of the disorder, weight limit has been reached, the onset age of appearance, basic personality traits, social difficulties and impaired family relationships.
Anorexia Nervosa Treatment
Three types of treatment have been proposed for anorexia nervosa: pharmacological, behavioural and cognitive-behavioral.
Pharmacological treatment focuses on associated symptoms and low-dose neuroleptics have been tested to increase impulse control, antidepressants, or appetite stimulants.
Behavioral treatments for AN include operating contingency management techniques in the hospital setting (e. g., rewarding intake with a family visit), desensitization programs to address the phobic component of the disorder, and exposure with response prevention to reduce binge eating and vomiting.
Finally, cognitive-behavioral treatments aim to identify and restructure irrational thoughts or dysfunctional ideas about body image.
Nutritional rehabilitation is the only well-established treatment for anorexia nervosa. Its objectives are to restore weight, normalize eating patterns, acquire signs of satiety and hunger, and correct biological and psychological consequences of malnutrition. They also address concerns related to weight gain and changes in body image.
Tips on how to deal with Anorexia Nervosa
- Prevention is critical for eating disorders. As we have seen, anorexia nervosa usually appears in early adolescence. Psychoeducation from early childhood on healthy eating can be one of the pillars for proper development.
- It is also important to provide children with healthy eating patterns in the various areas such as school and home.
- Adequate emotional and social development can be a protective factor. This can help through anxiety or stress management. As previously mentioned there is a relationship between anxiety and binge eating.
- Once anorexia nervosa is established, the restructuring of dysfunctional family patterns, bonding, and a strong support network help address the disorder.
- Strengthen self-image, self-concept, and self-esteem as the play an important role in cognitive distortions and attitudes about weight and body image. These can trigger the most difficult behaviors to modify the disorder (such as purging and binge eating).
Have you struggled with anorexia? Please leave us your comment below.
This article is originally written in Spanish by Dana Chis translated by Alejandra Salazar.
Psicóloga General Sanitaria. Defensora de la psicología en su vertiente más integral y de la formación continua. Es fundamental mantenernos actualizados ante los vertiginosos cambios de la sociedad en la que vivimos y así poder dar una respuesta lo más rápida y efectiva a la gran variabilidad de demandas que pueden surgir en nuestro día a día.