What is Anorexia?
Anorexia Nervosa, or simply anorexia, is an acute and potentially life threatening eating disorder. A person with anorexia becomes excessively thin due to extreme caloric restriction, fear of weight gain, and an obsession with their body weight and shape. A person with anorexia perceives themselves as overweight or fat even if they are dangerously thin and malnourished. They try to lose weight through strictly limited food intake and in some cases extreme exercise.
Although anorexia commonly develops during puberty or adolescence, it can affect individuals of any age, ethnicity, race, gender, and sexual orientation. Anorexia nervosa is diagnosed when a person’s body weight is 15% or less of their ideal body weight, and they consume food in very restrictive quantities (there are additional diagnostic criteria that are laid out in the DSM V). It is common for the restriction to progress to the point of the patient needing to be admitted to the hospital for monitored refeeding.
It is important to note that a patient is often struggling with anorexia long before the physical effects show. Restriction commonly progresses slowly and gradually sometimes unbeknownst to the patient. The urge to restrict is powerful and very strong and if the patient resists this urge, they will deal with very intrusive and loud negative thoughts that are quite disabling. For this reason, it’s often “easier” for the patient to give into the disordered urges.
Restriction, like all symptoms of an eating disorder, is a coping strategy. It would be considered a maladaptive coping strategy and leads to significant distress and physical danger if left untreated but it is effective for the patient who is using it. When a patient gets to the point of physical instability, they have been relying on this coping strategy for quite some time and will need help not only with refeeding but learning new, safer coping strategies.
Causes of Anorexia
Although the exact cause of anorexia is unidentified, it is widely accepted to be a combination of biological, psycho-social, familial and societal factors along with certain personality traits. In clinical practice, each case of anorexia is unique, though the physical presentation may be consistent from person to person. This is explained by the complicated interrelation of all of the contributing factors, which are completely individual in each case. In general, patients with anorexia tend to be overachievers and perfectionists, many with an underlying anxiety disorder.
Someone could be at risk of developing anorexia if:
- They are a perfectionist or have an obsessive personality, low self-esteem, or anxiety.
- Either the patient or a family member has a history of alcohol or drug addiction, depression or eating disorders
- They are excessively concerned about their appearance or are required/encouraged to have a particular body type for a hobby or career
- They have experienced criticism for your weight, shape, or eating habits
Diagnostic Criteria for Anorexia
According to the Fifth Edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), you must meet the criteria below before your anorexia diagnosis is conclusive:
- Restricting energy intake in comparison with requirements. The result is considerably low body weight for your physical health, developmental path, sex, and age.
- You have an extreme fear of becoming fat or gaining weight even though you are underweight.
- You self-evaluate and exert undue influence on your body, you are disturbed about how you experience your shape and weight, or you are in denial about the severity of your low body weight.
The DSM-5 criteria can rule out anorexia, but you could have another severe eating disorder such as atypical anorexia. Atypical anorexia is a disorder where you meet the DSM-5 criteria for anorexia without being underweight even after considerable weight loss. Studies have found that the psychological and medical effects of anorexia nervosa and atypical anorexia are the same.
Signs and Symptoms
Many symptoms of anorexia manifest either at its onset or when it has progressed. You need to consult a doctor if you:
- Lose weight significantly to a less than ideal weight
- Isolate yourself from friends and social activities
- Avoid eating in public and lie about the amount of food you have eaten
- Avoid whole food groups or macronutrients
- Base your self-esteem on how your body looks
- Are terrified of and obsessed with gaining weight
- Always complain about being fat and worry about weight, calories, food, and dieting
- Pretend not to be hungry even when you are, and you do not eat enough; therefore, you are underweight
- Stick to an excessive exercise schedule
- Continuously check your body in the mirror and layer your clothes to hide your weight and shape
- Vomit or misuse enemas, laxatives or diuretics
Symptoms secondary to restriction that indicate physical distress include:
- Have difficulty sleeping through the night.
- Experience dizziness or fainting
- Hair loss
- Heightened sensitivity to cold
- Irregular or absent menstrual periods
- Persistent fatigue fatigue
- Dehydration or constipation
- Irregular heartbeat
- Swollen legs or arms
Health Risks Arising From Anorexia
Anorexia can, in the long-term result in complications due to malnutrition. It is also a leading cause of deaths linked to mental health issues. Deaths from anorexia can be from physical issues or suicide. However, your health can improve and the problems alleviated if you resume healthy eating habits and address the underlying issues to prevent relapse into restriction.
Possible health risks of anorexia include:
- Muscle and bone problems, including osteoporosis, fatigue, weakness, and developmental problems in young adults and children.
- Heart and blood vessel problems such as low blood pressure, irregular heartbeat, heart failure, heart valve disease, and swollen face, hands, and feet.
- Problems with nerves and the brain such as seizures and impaired memory or concentration.
- Complications with kidneys or bowels
- Anemia or a weak immune system
- A decreased sex drive
- Fertility complications
There are many philosophies and approaches to treating anorexia nervosa because it can be quite difficult to treat and what each patient needs is so individual.
First and foremost, physical stability is the goal. If a patient is underweight, they need to be refed so that they are medically safe. Refeeding frequently takes place in a hospital or inpatient setting, where there is 24 hour supervision and support during meals and snacks from trained professionals. This usually yields the quickest results, with weight gain happening at a fairly rapid pace. Once a patient reaches their ideal body weight, they are discharged. Since the focus is exclusively on food and weight in these programs, when a patient transitions into normal life they are at high risk of slipping back into restrictive behaviour and ending up in exactly the same position.
An alternative to hospital refeeding is out-patient refeeding by a nutritionist or dietician, who specializes in eating disorder treatment. This is usually a slower process but can be more effective for some patients, especially those who have unsuccessfully completed hospital programs multiple times. This option is dependent on the comfort level of the nutrition professional and a patient would need to be visiting their family doctor regularly to assess physical stability. If weight gain wasn’t happening fast enough and a patient was in physical distress, they would need to be admitted to the hospital.
When a patient is underweight, cognitive capacity is impacted. They are less able to focus, process emotions effectively or think rationally. Therapy is often difficult during this time as a result. Typically during refeeding, a therapist would help a patient develop strategies to challenge eating disorder thoughts and urges and provide reassurance or encouragement.
After a patient with anorexia has been refed to a medically stable place, therapy can begin to address the underlying issues that contributed to the development of the eating disorder. Because there is less urgency for weight gain, the nutrition work can also shift to challenge eating disorder rules and improve intuition around eating as well as diversity of foods eaten.
Full recovery is possible. For anorexia treatment to be successful long-term, it must address both physical and psychological factors in tandem and the patient and their support network must understand that it’s a process, it requires commitment, patience and can often take a long time.