People who intentionally starve themselves into an emaciated state yet remain
convinced that they are overweight are suffering from a condition known as
anorexia nervosa. Anorexia is a severe emotional disorder that 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. People with anorexia are
terrified of becoming obese and refuse to maintain a normal weight, putting
themselves in danger of starvation.
Anorexia rarely begins in people who are older than 40 years of age. It most
commonly appears in the teenage years, affecting up to 3 in 100 adolescents.
Although anorexia seldom emerges before puberty, associated mental conditions,
such as depression and obsessive-compulsive behavior, are usually more severe
when it does. The onset of anorexia is often preceded by a traumatic or
stressful event and it is usually accompanied by other emotional difficulties.
Anorexia is a life-threatening condition that can result in death from
starvation, heart failure, electrolyte imbalance, or suicide.
There are two main types of anorexia nervosa:
Restricting Type—characterized by dieting,
fasting, and/or excessive exercise
(anorexic-bulimic)—characterized by self-induced
vomiting and/or misuse of laxatives, enemas, and/or diuretics. Binge eating may
or may not occur; purging is common even after small amounts of food have been
eaten. This type carries greater medical risk.
Signs and Symptoms
The primary sign of anorexia nervosa is severe weight loss, accompanied by
any number of physical and psychological symptoms and unusual behaviors related
to food, eating, or exercise. A person for whom a healthy weight would be 125
pounds, for example, may drop 20, or even as much as 60 pounds below this. At
the same time, the person may insist that he or she is overweight.
Scanty or absent menstrual periods
Cold or swollen hands and feet
Bloated or upset stomach
Distorted perception of self (that is, a great difference between how
an individual believes he or she looks and his or her actual physical
Inability to remember things
Refusal to acknowledge the gravity of the illness
Obsessive-compulsive behavior (excessive need to control personal
Depression (feelings of ineffectiveness; loss of interest in friends
and former activities; lack of spontaneity; rigid thinking; lack of initiative;
flattened emotional response; irritability; insomnia; diminished interest in
Unusual behaviors related to food or eating (for example, hoarding or
concealing food, refusing to eat in public, eating only one type of food,
ritually cutting food into tiny pieces, intense study of diets and calories,
planning and preparing elaborate meals for others)
Preoccupation with body size or body image
Preoccupation with weight control,
There is no specific cause of anorexia. Medical experts agree that several
factors work together in a complex fashion to lead to the eating disorder. These
Severe trauma or emotional stress (such as the death of a loved one or
sexual abuse) during puberty or prepuberty.
Abnormalities in brain chemistry. Changes in serotonin levels, a brain
chemical that regulates appetite, may contribute to other symptoms of anorexia
nervosa such as depression, impulsiveness, obsessive behaviors, or other mood
disorders. In addition, the process of purging may deplete tryptophan, an amino
acid necessary for the production of serotonin, leading to further
A cultural environment that puts a high value on thin or lean
Overbearing, controlling, and critical parents who do not show
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. Because perfection is impossible, the
inability to attain perfection reinforces the person's sense of being unworthy
of being loved. Not eating, according to some experts, is a passive act of
revenge directed toward those who will never love the person because of his or
her lack of perfection.
Family history of anorexia. About one-fifth of those with anorexia
have a relative with an eating disorder. In fact, it is common to discover that
someone with anorexia has a mother or sister with this eating disorder as well.
If one identical twin has anorexia, the other has more than a 50% chance of also
developing it. It is not clear, however, to what extent this family connection
is due to heredity and or to learned behavior.
Infection. Some researchers report an association between
beta-hemolytic streptococcal infection or Epstein Barr virus (the virus that
causes mononucleosis) and development of
Age and gender—anorexia is most common in
teens and young adult women
Early onset of puberty
Living in an industrialized country
Depression—although depression is associated
with the development of anorexia, it does not cause the disorder. Depression in
a family member also appears to increase the likelihood of developing an eating
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); phobia,
another type of anxiety disorder that may also be present in someone with an
eating disorder, and/or OCD tend to emerge before the eating disorder while
panic attacks may develop after the diagnosis is made.
Avoidant and/or narcissistic personality
disorder(s)—approximately one-third of those with the
restricting type of anorexia have avoidant personalities, which is characterized
by feelings of inadequacy, social inhibition, extreme sensitivity to negative
comments or criticism, and avoidance of interpersonal relationships, both at
work and on an intimate level. Borderline personality disorder (exceptionally
unstable interpersonal relationships, extremely poor self-image, and excessively
impulsive behaviors) may be a risk factor as well but such individuals are more
likely to develop bulimia.
Participation in sports and professions that put emphasis on 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
While your healthcare provider will rely on points discussed in
Signs and Symptoms such as excessive weight
loss, refusal to maintain normal body weight, and distorted self-perception, he
or she will also ask a series of questions to better determine whether or not
anorexia is present. The SCOFF questionnaire, developed in Great Britain, is
proving to be a very reliable method for diagnosing anorexia. A "yes" response
to at least two of the following questions is a strong indicator of an eating
S "Do you feel sick because you feel full?"
"Do you lose control over how much you eat?"
"Have you lost more than 13 pounds recently?"
"Do you believe that you are fat when others say that you are thin?"
F "Does food and/or thoughts of food dominate your life?"
If an eating disorder is suspected, the healthcare provider will order a
number of laboratory tests. These serve to determine blood count (to assess for
signs of anemia that may be related to lack of iron or vitamin B12), levels of
electrolytes (minerals such as potassium, calcium, and magnesium), amylase
(serum amylase is elevated when there is frequent vomiting), and protein, and
kidney, liver, and thyroid functions. He or she may also order an
electrocardiogram (which gives a graphic record of the electrical activity of
the heart); this may be abnormal if there is a deficiency in an electrolyte or
nutrient such as potassium or calcium. If a diagnosis of anorexia is made, the
healthcare provider will require frequent office visits to monitor the
condition. It is best for a person with anorexia to work with a
multidisciplinary team including his or her primary care physician, a
psychologist or psychiatrist, and a registered dietitian.
The most effective prevention strategy is the development, from an early age,
of healthy eating habits and a strong body image. Cultural values that place a
premium on lean or thin bodies need to be questioned. Education about the
life-threatening nature of anorexia is also an important part of prevention.
In those who have already been diagnosed and treated for anorexia, avoiding
recurrence of the eating disorder is the primary goal.
Family and friends should be urged not to focus on the patient's
condition or on issues of food or weight. Mealtimes, for example, should be
reserved for social interaction and relaxation, without any discussion of the
Careful and frequent monitoring of weight and other physical signs by
the healthcare provider can reveal signs of a relapse.
Cognitive or other forms of
psychotherapy can help the person
to develop coping skills and change the unhealthy thought processes that
underlie anorexia nervosa.
Family therapy is helpful in addressing underlying contributing
factors in the home environment and in enlisting the support and understanding
of family members.
Anorexia demands a multipronged treatment plan that addresses both the
physical and psychological aspects of this disorder.
often in combination with
antidepressants, is a very effective
therapeutic approach for treatment of eating disorders. Complementary and
alternative methods of treatment (such as the use of
mind/body medicine) are valuable
adjuncts to usual ways of stimulating appetite, addressing nutritional problems,
and helping the patient to develop a healthier body image and to learn to deal
more productively with stress.
In general, the most important aspect of treating anorexia is restoring
weight and preventing starvation. For this, hospitalization may be necessary,
particularly under the following circumstances:
Continuing weight loss, in spite of outpatient treatment
Body mass index (BMI; a measurement that takes into account a person's
height and weight) 30% below normal; normal range is 19 to 24
Irregular heart rhythm
Low potassium levels
Low blood pressure
Generally, adequate weight gain (1 to 2 pounds per week) and appropriate
changes in behavior require a 10 to 12 week hospital stay. (Most insurance in
the United States, however, covers only 15 days of inpatient treatment.) To
avoid bloating, abdominal upset, and fluid retention, those who are severely
malnourished may be started on a diet of 1,500 calories a day, gradually
increasing to as much as 3,500 calories. Because anorexia triggers changes in
metabolism, high caloric intake may be necessary to stimulate weight gain.
Unfortunately, there is no completely effective treatment for anorexia
nervosa, and recovery can take many years. Even after some weight gain, many
people with anorexia remain quite thin and risk of relapse is very high. A
number of influences in the social environment may make recovery difficult:
Friends or family who express admiration or envy of the patient's
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
A patient's persistent belief that emaciation is not only normal but
attractive and/or that purging is the only way to avoid becoming
Soliciting the involvement of friends, family members, and others in the
treatment of the individual, with education for everyone regarding the gravity
of the disease, may diminish these influences.
Treating anorexia nervosa involves major lifestyle changes. Not only must
eating habits be altered, but the individual must adjust his or her self
perception to no longer hold a distorted body image. The following lifestyle
changes may help in this process:
Establishing regular eating habits and a healthy diet
Developing a support system and participating in a support group for
help with stress and emotional issues
Cutting back on exercise if obsessive exercise has been part of the
disease. Once sufficient weight gain has been established, controlled exercise
regimens can be a positive reinforcement for appropriate eating habits and a way
to reduce gastrointestinal distress.
Anorexia nervosa in some ways resembles other major psychiatric disorders
such as depression and obsessive-compulsive disorder, because some of the
symptoms of these disorders, for example obsessive behavior, lack of enjoyment
from life, and severely distorted perception of reality (in this case, of the
body), are exhibited by people with anorexia. This has led to the use of
antidepressants for anorexia, particularly selective serotonin reuptake
inhibitors (SSRIs), because these drugs are first-line treatments for OCD and
depression. Medications, however, do not work alone and must be used in
conjunction with a multidisciplinary approach that includes
nutritional interventions and
Serotonin Reuptake Inhibitors
Studies suggest that fluoxetine may increase weight and improve mood over
several months in people with anorexia nervosa and depression. Similarly
positive results were obtained in a preliminary study of anorexics whose body
weight had already been partly restored.
This class of antidepressants, including imipramine and desipramine, tend to
be more effective for bulimia than anorexia.
One study suggests that clomipramine has the potential to stimulate weight
gain and improve symptoms of anorexia, but more research is needed on the value
of this drug in treating this particular eating disorder.
In a study using high doses of cyproheptadine hydrochloride, which is thought
to stimulate appetite, the number of days necessary to achieve appropriate
weight gain were decreased and depression was relieved in those with restricting
Estrogen together with progesterone may be used to restore normal menstrual
cycles. This, however, does not generally have any effect on weight.
Nutrition and Dietary Supplements
Anorexics with low body weight, low
BMI, and low serum albumin (the
main protein in blood) levels are at increased risk for vitamin and mineral
deficiency. Vitamin abnormalities may contribute to cognitive difficulties such
as poor judgment or memory loss and other psychiatric conditions. These
deficiencies can often be corrected with dietary interventions. Therefore, an
important part of treatment is to include a multivitamin with minerals
Vitamin B Complex
Deficiencies in vitamins B2 (riboflavin) and B6 (pyridoxine) have been noted
in those with anorexia, with some studies suggesting that deficiency of these B
vitamins is present in approximately 20% of anorexic patients admitted to the
hospital for treatment. One small study of 13 people with anorexia found 33% of
the participants were deficient in vitamins B2 and B6 may be deficient in as
many as 33% of those with this eating disorder. Dietary changes alone, without
additional supplements, often can bring vitamin B levels back to normal.
Inadequate intake of calories, protein, and micronutrients over a prolonged
period of time, as seen in people with anorexia, may cause oxidative stress,
particularly when coupled with excessive physical activity. Oxidative stress is
a process in which certain substances in the body generated from metabolism
(breakdown of tissue for energy) cause cell damage. Antioxidants, such as
vitamins A, C, and E, are substances that can help protect the body from the
damage of oxidative stress. In a study comparing antioxidant levels in healthy
female adolescents to those with anorexia, researchers found that the anorexic
group had reduced amounts of these protective substances, such as vitamin E, and
that the antioxidants were not as active in the blood as they normally would be.
It is unclear, however, whether supplementation with antioxidants including
vitamins E and C, beta-carotene, coenzyme Q10, and selenium will correct
deficiencies in people with anorexia or improve their treatment in any way.
Currently, supplementation with antioxidants is not part of standard care for
anorexia, but is being explored scientifically.
Zinc influences appetite, taste, smell, vision, and cognitive function and is
an essential nutrient for protein synthesis, growth, and wound healing. The
symptoms of zinc deficiency include loss of appetite, weight loss, skin
abnormalities, lack of menstruation, and depression. Studies have revealed that
zinc deficiencies are common in those with anorexia nervosa and may contribute
to a number of the symptoms of the condition.
Zinc supplementation has demonstrated the following benefits in
Restoring normal zinc levels
Increasing the rate of weight gain
While zinc supplementation may be helpful as an addition to standard
treatment for anorexia, there are a number of different forms of zinc and more
research is needed to determine which is most effective and at what dosage.
Women with anorexia nervosa are at increased risk for bone fractures and can
develop osteoporosis at a younger age than women without eating disorders. It
has been observed that adolescents and young adults with anorexia nervosa tend
to have low levels of DHEA, a hormone produced by the adrenal glands. This is
important because DHEA levels have been associated with bone mineral density,
suggesting that this hormone may play a role in preventing bone loss and
stimulating bone formation. Some preliminary studies suggest that women with
anorexia who take 50 mg of DHEA per day are able to restore normal levels of
this and other hormones, such as estrogen and testosterone, and show signs of
protection from bone loss.
Essential Fatty Acids
Polyunaturated fatty acids (PUFAs), such as gamma-linolenic acid (an omega-6
fatty acid) and alpha-linolenic acid (an omega-3 fatty acid), are essential for
normal growth and development. They are not made by the body and must therefore
be obtained through the diet. Studies suggest that women, and possibly men, with
anorexia nervosa have lower than optimal levels of PUFAs and display
abnormalities in the use of these fatty acids in the body. To prevent the
metabolic complications associated with essential fatty acid deficiencies, some
recommend that treatment programs for anorexia nervosa include PUFA-rich foods
such as organ meats and fish.
Melatonin is a hormone produced in the brain that regulates sleep. Studies
show that fluctuations in melatonin levels may influence the symptoms of
anorexia. For example, abnormally high melatonin levels may cause depressed mood
and daytime sleepiness in those with anorexia. While people with restricting
type of anorexia usually have normal melatonin levels, studies have found that
those with binge and purge anorexia, and anorexia in combination with depression
have abnormal fluctuations and levels of melatonin. Melatonin levels may play a
role in the symptoms of anorexia, but it is not known whether supplementation
will change the course of the disease. Some researchers speculate, however, that
melatonin levels in people with anorexia may indicate who is likely to benefit
from antidepressant medications.
While the following appetite stimulants have not been studied for the
treatment of anorexia nervosa, they have been used in certain traditional
healing systems to stimulate appetite and may be recommended as a complementary
therapy by an herbal specialist:
Angelica root (Angelica archangelica)
Blessed thistle herb(Cnicus benedictus)
Gentian root (Gentiana lutea)
Cinnamon bark (Cinnamomum verum)
Dandelion herb and root (Taraxacum
In cases of significant weight loss where the muscles begin to deteriorate,
some herbalists may recommend fenugreek seed (Trigonella foenum-graecum).
Skullcap (Scutellaria lateriflora) may be used to relax the nerves and
Roman chamomile (Chamaemelum nobile) may be used to treat depression
associated with anorexia.
Massage and Physical Therapy
Massage appears to be a helpful component of treatment for anorexia nervosa.
In one study, a group of adolescents with anorexia received massages twice
weekly for one month, in addition to standard daily group therapy. The massaged
adolescents reported lower anxiety levels and improved body image compared to
adolescents with anorexia receiving only standard daily group therapy.
Measurably reduced cortisol (a marker of stress) and increased dopamine (a brain
chemical associated with relaxation) concentrations were also observed in the
A professional homeopath can provide supportive care to address various
aspects of anorexia. Because of the seriousness of the condition, anorexic
people are advised against treating themselves with homeopathic remedies.
Cognitive Behavioral Therapy
Cognitive-behavioral therapy is reported to be one of the most effective
therapies for anorexia. It is based on the assumption that anorexia develops in
response to life stresses. Treatment is aimed at confronting the individual's
fears and avoidance behaviors and cultivating new problem-solving skills. It
also aims to increase awareness of negative thought processes and to change
them. Cognitive techniques are used to encourage patients to evaluate and
challenge their automatic thoughts, examine their underlying assumptions, and
replace them with realistic beliefs and actions based on reasonable
Family therapy is recommended for both children and adults, in addition to
individual therapy for the person with anorexia. Parents and other family
members often have intense feelings of guilt and anxiety that they need to
address. They may actually support the individual's eating disorder out of these
feelings or perhaps they, too, put a premium on being thin. Family therapy is
aimed, in part, at helping the parents or partner (in the case of an adult)
understand the medical gravity of this illness and the ways in which they may be
inadvertently contributing to it.
Hypnosis has been shown to be successful as part of an integrated treatment
program for anorexia nervosa. Evidence suggests that purging anorexics have a
greater hypnotic ability—and thus may be more likely to
benefit from hypnosis—than restrictive anorexics.
Hypnosis reportedly strengthens both self-confidence and the ability to cope,
which may result in healthier eating, improved body image, and greater
self-esteem. Whether or not the treatment is successful may depend on the number
of sessions; individual programs have generally involved 1-hour per week for 3
months followed by bi-weekly sessions until treatment is no longer needed.
Studies suggest that biofeedback may be helpful in reducing stress in people
Anorexia poses a number of potential problems for the woman who is pregnant
or wishes to become pregnant:
Difficulty getting pregnant/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 being triggered from the stress of pregnancy
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 (particularly
with binge-purge types)
Hormonal changes (can lead to absence of menstrual periods,
infertility, bone loss, and stunted growth)
Seizures and/or numbness in hands and feet
Death (suicide is responsible for 50% of fatalities associated with
The outlook for individuals with anorexia is variable, with recovery taking
between 4 and 7 years. There is also a high chance of disease recurrence even
after recovery. Long-term studies show that 50% to 70% of people recover from
anorexia nervosa; however, 25% do not fully recover. Many, even after they are
considered "cured," continue to exhibit traits of anorexia such as remaining
very thin and striving for perfection.
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Review Date: June 2001
Reviewed By: Participants in the review process include: John Balletto, LMT, NCTMB, Center
for Muscular Therapy, President, Providence, RI; Ruth Debusk, RD, PhD, Editor,
Nutrition in Complementary Care, Tallahassee, FL; Scott Shannon, MD, Integrative
Psychiatry, Medical Director, McKee Hospital Center for Holistic Medicine, Fort
Collins, CO; R. Lynn Shumake, PD, Director, Alternative Medicine Apothecary,
Blue Mountain Apothecary & Healing Arts, University of Maryland Medical
Center, Glenwood, MD.
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