Anorexia nervosa is a psychiatric diagnosis that describes an eating disorder characterized by low body weight and body image distortion with an obsessive fear of gaining weight. Individuals with anorexia are known to commonly control body weight through the means of voluntary starvation, purging, vomiting, excessive exercise, or other weight management measures, such as diet pills or diuretic drugs. It primarily affects adolescent females, however now it is seen that approximately 10% of people with the diagnosis are male. Anorexia nervosa is a complex condition, involving neurobiological, psychological, and sociological components.

Anorexia Nervosa is a Serious Problem Among Both Sexes 

Anorexia or eating disorder usually associated with teenage girls is increasingly spreading in epidemic proportion among men seeking to build "an ideal body". 

It is believed that the number of males affected by anorexia is much higher than the numbers reported., because many men never seek treatment for the disease. Because many cases go unreported, there is a "cloak" over what many experts are calling, "an unrecognized spiraling problem of epidemic proportions".  Much of the blame is being pointed at the media which is constantly show casing many with thinner and thinner images of what is convincing our population, is the "ideal body". " 

According to the first nationally representative study of eating disorders in the United States, which appeared in the February 2007 edition of Biological Psychiatry, 0.9 percent of women and 0.3 percent of men reported suffering from anorexia in their lifetime.

The Academy for eating disorders reports that nearly 50 percent of anorexia sufferers recover, while 33 percent show some improvement and 20 percent continue to be severely ill.

An average woman gains 25 lbs during pregnancy, while restricting anorexics gain an average of 15.8 lbs during pregnancy.

The average birth weight of babies born to purging anorexics is 4.9 lbs.

Approximately 0.56 percent of anorexia sufferers will die each year, while 5.6 percent will die each decade.

The mortality rate among people with anorexia is 12 times higher than the mortality rate for all causes of death among females aged 15-24.

1 in 5 anorexia sufferers will suffer related complications such as suicide attempts and heart problems that lead to premature death.

An estimated 5 to 15 percent of anorexia and bulimia sufferers are male.

Symptoms of Anorexia Nervosa 

There are a number of symptoms of anorexia nervosa that although not necessarily diagnostic of anorexia, have been found to be commonly (but not exclusively) present in those with this eating disorder. The symptoms of anorexia nervosa can be basically classified into physical and psychological.

Physical Symptoms of Anorexia Nervosa

Anorexia nervosa can put a serious strain on many of the body's organs and physiological resources, particularly on the structure and function of the heart and cardiovascular system. People with anorexia nervosa typically have a disturbed electrolyte balance, particularly low levels of phosphate, which has been linked to heart attack, muscle weakness, immune dysfunction, and ultimately death.

Those who develop anorexia before adulthood may suffer stunted growth and hormone disorders (including sex hormones) and chronically increased cortisol levels.

Osteoporosis can also develop as a result of anorexia in 38-50% of cases, as poor nutrition leads to the retarded growth of essential bone structure and low bone mineral density.

Anorexia does not harm everyone in the same way. For example, evidence suggests that the results of the disease in adolescents may differ from those in adults.

Changes in brain structure and function are early signs of the condition. Enlargement of the ventricles of the brain is thought to be associated with starvation, and is partially reversed when normal weight is regained.

Anorexia is also linked to reduced blood flow in the temporal lobes, although since this finding does not correlate with current weight, it is possible that it is a risk trait rather than an effect of starvation.

Other physical symptoms of anorexia may include the following:

• Extreme weight loss
• Endocrine disorder, leading to cessation of periods in girls.
• Impotence in males
• Starvation symptoms, such as reduced metabolism, slow heart rate.
• Reduction in white blood cell count
• Pallid complexion and sunken eyes
• Creaking joints and bones
• Tooth decay
• Constipation
• Dry skin
• Dry or chapped lips
• Headaches
• Brittle fingernails
• Bruising easily

Psychological Symptoms of Anorexia Nervosa

• Distorted body image
• Poor insight
• Pre-occupation or obsessive thoughts about food and weight
• Perfectionism
• Obessive Compulsive Disorder (OCD)
• Belief that control over food or body is synonymous with being in control of one's life

Causes of Anorexia Nervosa

It is clear that there is no single cause for anorexia and that it stems from a mixture of biological, social, and psychological factors. Current research is commonly focused on explaining existing factors and uncovering new causes. However, there is considerable debate over how much each of the known causes contributes to the development of anorexia. In particular, the contribution of perceived media pressure on women to be thin has been especially contentious. 

Psychological Factors that Cause Anorexia Nervosa

There has been a significant amount of work into psychological factors that suggests how biases in thinking and perception help maintain or contribute to the risk of developing anorexia.

Anorexic eating behavior is thought to originate from feelings of fatness and unattractiveness and is maintained by various cognitive biases that alter how the affected individual evaluates and thinks about their body, food and eating.

One of the most well-known findings is that people with anorexia tend to over-estimate the size or fatness of their own bodies. A recent review of research in this area suggests that this is not a perceptual problem, but one of how the perceptual information is evaluated by the affected person. Recent research suggests people with anorexia nervosa may lack a type of overconfidence bias in which the majority of people feel themselves more attractive than others would rate them. In contrast, people with anorexia nervosa seem to more accurately judge their own attractiveness compared to unaffected people, meaning that they potentially lack this self-esteem boosting bias.

People with anorexia have been found to have certain personality traits that are thought to predispose them to develop eating disorders. High levels of obsession (being subject to intrusive thoughts about food and weight-related issues), restraint (being able to fight temptation), and clinical levels of perfectionism (the pathological pursuit of personal high-standards and the need for control) have been cited as commonly reported factors in research studies.

Physiological factors that Cause Anorexia Nervosa

Zinc deficiency causes a decrease in appetite that can degenerate in anorexia nervosa (AN), appetite disorders and, notably, inadequate zinc content in the body. The use of zinc in the treatment of anorexia nervosa has been advocated since 1979 by Bakan. At least five trials showed that zinc improved weight gain in anorexia. A 1994 randomized, double-blind, placebo-controlled trial showed that zinc (14 mg per day) doubled the rate of body mass increase in the treatment of AN. Deficiency of other nutrients such as tyrosine and tryptophan (precursors of the monoamine neurotransmitters norepinephrine and serotonin, respectively), as well as vitamin B1 (thiamine) could contribute to this phenomenon of malnutrition-induced malnutrition.

There are strong correlations between the neurotransmitter serotonin and various psychological symptoms such as mood, sleep, emesis (vomiting), sexuality and appetite. A recent review of the scientific literature has suggested that anorexia is linked to a disturbed serotonin system, particularly to high levels at areas in the brain with a system particularly linked to anxiety, mood and impulse control. Starvation has been hypothesized to be a response to these effects, as it is known to lower tryptophan and steroid hormone metabolism, which, in turn, might reduce serotonin levels.

Family and twin studies have suggested that genetic factors contribute to about 50% of the variance for the development of an eating disorder and that anorexia shares a genetic risk with clinical depression. This evidence suggests that genes influencing both eating regulation, and personality and emotion, may be important contributing factors.

Risk Factors of Anorexia Nervosa

• Anorexia is most common in teens and young adult women
• Early onset of puberty
• Living in an industrialized country
• 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 disorder.
• Obessive 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.
• 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 .
• History of sexual abuse or other traumatic event
• Dieting

Diagnosing Anorexia Nervosa

Although biological tests can aid the diagnosis of anorexia, the diagnosis is based on a combination of behavior, reported beliefs and experiences, and physical characteristics of the patient. Anorexia is typically diagnosed by a clinical psychologist, psychiatrist or other suitably qualified clinician. Notably, diagnostic criteria are intended to assist clinicians, and are not intended to be representative of what an individual sufferer feels or experiences in living with the illness.

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Most anorexics deny that they are ill and are usually brought to treatment by a family member.

Most anorexics are diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea (failure to menstruate) in females, and sometimes of abdominal pain, constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15% below normal, with some allowance for body build and weight history.

The doctor will need to rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic syndrome, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatments for Anorexia Nervosa

The first line treatment for anorexia is usually focused on immediate weight gain, especially with those who have particularly serious conditions that require hospitalization. In particularly serious cases, this may be done as an involuntary hospital treatment under mental health law, where such legislations exist. In the majority of cases, however, people with anorexia are treated as outpatients, with input from physicians, psychiatrists, clinical psychologists and other mental health professionals.

A recent clinical review has suggested that psychotherapy is an effective form of treatment and can lead to restoration of weight, return of menses among female patients, and improved psychological and social functioning when compared to simple support or education programs. However, this review also noted that there are only a small number of randomized controlled trials on which to base this recommendation, and no specific type of psychotherapy seems to show any overall advantage when compared to other types. Family therapy has also been found to be an effective treatment for adolescents with anorexia and in particular. This a method is widely used and found to maintain improvement over time.

Drug treatments, such as SSRI or other antidepressant medication, have not been found to be generally effective for either treating anorexia, or preventing relapse although it has also been noted that there is a lack of adequate research in this area. It is common, however, for antidepressants to be prescribed, often with the intent of trying to treat the associated anxiety and depression.

Supplements  of  14mg/day of zinc is recommended as routine treatment for anorexia nervosa due to a study showing a doubling of weight regain after treatment with zinc was begun. The mechanism of action is hypothesized to be an increased effectiveness of neurotransmission in various parts of the brain, including the amygdala, after adequate zinc intake begins resulting in increased appetite.

There are various non-profit and community groups that offer support and advice to people who suffer from anorexia or who care for someone who does.

Alternate medicines for Anorexia Nervosa

Herbal Treatment for Anorexia Nervosa

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 officinale)

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 for Anorexia Nervosa

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 treatment group.

Homeopathy for Anorexia Nervosa

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.

Living with Anorexia Nervosa

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 disease.
• Careful and frequent monitoring of weight management 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.

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. 

Prognosis for Anorexia Nervosa

 Anorexia is thought to have the highest mortality rate of any psychiatric disorder, with approximately 6% of those who are diagnosed with the disorder eventually dying due to related causes. The suicide rate of people with anorexia is also higher than that of the general population and is thought to be the major cause of death for those with the condition. 

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.

Current Developments in Anorexia Nervosa

This review summarizes recent clinical developments, topics of debate, and research findings in relation to anorexia nervosa in children and adolescents. Following an update of diagnostic and prevalence issues, recent developments in treatment approaches are discussed. These cover recommendations for the medical management of anorexia nervosa in young people, as well as psychological interventions for children, adolescents and their families. The question of which type of service setting is most appropriate for the treatment of young people with anorexia nervosa remains a subject of discussion, and recent guidance and work in this area is presented. Finally, the ongoing relatively poor prognosis in terms of general mental health associated with anorexia nervosa is highlighted and the implications for CAMHS practitioners discussed. 

The course and outcome of anorexia nervosa vary across individuals: some fully recover after a single episode; some have a fluctuating pattern of weight gain and relapse; and others experience a chronically deteriorating course of illness over many years. The mortality rate among people with anorexia has been estimated at 0.56 percent per year, or approximately 5.6 percent per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population. The most common causes of death are complications of the disorder, such as cardiac arrest or electrolyte imbalance, and suicide. 

The following result from current researches demonstrates the unknown quality and severity of the disorder known as Anorexia nervosa. 

• Anorexia nervosa is a disorder of unknown etiology with a high rate of relapse and no known treatment.
• Anorexia nervosa and bulimia nervosa are eating disorders that strike a significant number of adolescent and young adult women and carry a significant morbidity and mortality. Over the last 30 years, virtually every class of psychiatric drug as well as atypical agents have been tested in the management of these vexing and often chronic disorders. For anorexia nervosa, there is little if any role for pharmacotherapy.
• Anorexia nervosa and bulimia nervosa remain enigmatic disorders with poorly understood etiologies. Clinicians continue to find these disorders very challenging to treat. As their underlying pathophysiology is clarified, it is hoped that specific pharmacologic treatments will be developed to alleviate the pain and disability these disorders produce.
• The results of a study on students in Egypt confirmed the initial impression that disorders of eating are emerging in cultures that did not produce such morbidity in the past, with more or less the same prevalence as in the United States. The study concludes that no society is truly immune to the development of such disorders, because of the globalization of culture by virtue of the media.
• Anorexia can have devastating outcome. There is a high rate of treatment failures and recidivism among anorectic patients.

For More Information on Anorexia Nervosa

Books on Anorexia Nervosa

• Hall, Lindsey, and Monika Ostroff. Anorexia Nervosa: A Guide to Recovery. Carlsbad, CA: Gurze Design & Books, 1998.
• Hornbacher, Marya. Wasted: A Memoir of Anorexia and Bulimia. New York: Harpercollins, 1999.
• Robbins, Paul R. Anorexia and Bulimia. Hillside, NJ: Enslow Publishers, 1998.

Organizations for Anorexia Nervosa

• American Anorexia/Bulimia Association. 165 West 46th Street, Suite 1108, New York, NY 10036. (212) 575–6200.
• Anorexia Nervosa and Related Eating Disorders. PO Box 5102, Eugene, OR 97405. (541) 344–1144.
• Center for the Study of Anorexia and Bulimia. 1 W. 91st Street, New York, NY 10024. (212) 595–3449.
• Eating Disorder Awareness & Prevention. 603 Steward St., Suite 803, Seattle, WA 98101. (206) 382–3587.
• National Association of Anorexia Nervosa and Associated Disorders. Box 7, Highland Park, IL 60035. (708) 831–3438.
• National Eating Disorders Organization. 6655 South Yale Avenue, Tulsa, OK 74136. (918) 481–4044.
• National Institute of Mental Health Eating Disorders Program. Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496–1891.