Anorexia nervosa is characterized by a relentless pursuit of thinness, a distorted body image, an extreme fear of obesity, refusal to maintain a minimally normal body weight, and, in women, the absence of menstrual periods.

• Anorexia nervosa usually begins during adolescence and is more common among females.
• People with anorexia constantly diet despite continued weight loss, are obsessed with food, and deny that they have a problem.
• Severe or rapid weight loss can have life-threatening consequences.
• Doctors base the diagnosis on symptoms and do a physical examination and tests to check for adverse effects of excessive weight loss.
• Cognitive-behavioral therapy, usually for 1 to 2 years, can help.

Hereditary and social factors play a role in the development of anorexia nervosa. The desire to be thin pervades Western society, and obesity is considered unattractive, unhealthy, and undesirable. Even before adolescence, children are aware of these attitudes, and more than half of preadolescent girls diet or take other measures to control their weight. Yet only a small percentage of these girls develop anorexia nervosa. Other factors, such as psychologic susceptibility, probably predispose certain people to develop anorexia nervosa. In areas with a genuine food shortage, anorexia nervosa is rare.

The disorder usually begins during adolescence, occasionally earlier, and less commonly during adulthood. Anorexia nervosa affects primarily people in middle and upper socioeconomic classes. In Western society, the number of people who have this disorder seems to be increasing. About 0.9% of females have severe anorexia nervosa, compared with only about 0.3% of males. However, mild cases may not be identified.

Did You Know? Between one third and one half of people with anorexia nervosa binge and then purge.

Symptoms

Anorexia nervosa may be mild and transient or severe and persistent.

The first indications of the impending disorder may be a subtle increased concern with diet and body weight. Such concerns seem out of place because most people who have anorexia nervosa are already thin. Preoccupation and anxiety about weight intensify as people become thinner. Even when emaciated, people claim to feel fat, deny that anything is wrong, do not complain about weight loss, and usually resist treatment.

Anorexia means lack of appetite, but people who have anorexia nervosa are actually hungry and preoccupied with food. They study diets and count calories. They hoard, conceal, and deliberately waste food. They collect recipes and prepare elaborate meals for others.

About 30 to 50% of people who have anorexia nervosa binge and then purge by vomiting or taking laxatives. The others simply restrict the amount of food they eat. They also frequently lie about how much they have eaten and conceal their vomiting and their peculiar dietary habits. Many people also take diuretics (drugs that cause the kidneys to excrete more water) to treat perceived bloating and in an effort to lose weight.

Women with anorexia nervosa stop having menstrual periods, sometimes before losing much weight. Women and men may lose interest in sex. Typically, they have a low heart rate, low blood pressure, a low body temperature, and fine soft hair or excess body and facial hair. Tissues swell because fluid accumulates (called edema). People commonly report bloating, abdominal distress, and constipation. Self-induced vomiting can erode tooth enamel, enlarge the salivary glands in the cheeks (parotid glands), and inflame the esophagus. Depression is common.

Even when people become very thin, they tend to remain active, often exercising excessively to control their weight. Until they become emaciated, they have few symptoms of nutritional deficiencies.

Hormonal changes resulting from anorexia nervosa include markedly reduced levels of estrogen (in women) and thyroid hormone and increased levels of cortisol. If people become severely malnourished, every major organ system in the body is likely to be affected. Bone density may decrease, increasing the risk of osteoporosis.

Recognizing Anorexia
People who have anorexia usually deny they have a problem and try to conceal their unusual eating habits rather than seek help. Because many people who have anorexia are meticulous, compulsive, and intelligent, with very high standards for achievement and success, they are often able to conceal the disorder until it is severe. Thus, family members and friends may be unaware of the disorder until it has become severe. Because anorexia has serious, sometimes life-threatening complications, family members and friends of someone who often diets or is excessively concerned about weight need to know how to recognize the disorder. People with anorexia often do the following: Complain about being fat although they are very thin Deny being thin Think about food all the time Measure their food Hoard, conceal, or deliberately waste food Prepare elaborate meals for others Skip meals Pretend to eat or lie about how much they have eaten Exercise compulsively Dress in bulky clothing or many layers Weigh themselves several times a day Base their self-esteem on how thin they are

Rapid or severe weight loss can cause life-threatening problems. Problems with the heart and with fluids and electrolytes (sodium, potassium, chloride) are the most dangerous:

• The heart gets weaker and pumps less blood through the body:
• Heart rhythm may become abnormal.
• People may become dehydrated and prone to fainting.
• The blood may become alkaline (a condition called metabolic alkalosis (see Acid-Base Balance: Alkalosis).
• Potassium levels in the blood may decrease.

Vomiting and taking laxatives and diuretics can worsen the situation. Sudden death, probably due to abnormal heart rhythms, may occur.

Diagnosis

Because people do not think they have a problem, they resist evaluation and treatment. Usually, they are brought to the doctor's office by family members, or they come because of another disorder. Doctors measure height and weight. Doctors also ask people how they feel about their body and weight and whether they have other symptoms. Doctors may use questionnaires developed to detect eating disorders. If people have the following, anorexia is likely:

• A low body weight, with a body mass index (BMI) of less than 17.5
• Fear of obesity
• Denial of illness
• Absence of menstrual periods in women

Doctors also do a physical examination and blood and urine tests to check for effects of weight loss and undernutrition. A bone density test may be done to check for loss of bone density. Electrocardiography (ECG) may be done to check for abnormal heart rhythms.

Did You Know? Without treatment, nearly 10% of people with severe anorexia nervosa die.

Prognosis

Without treatment, nearly 10% of people with severe anorexia die. When symptoms are mild and unrecognized, people rarely die. With treatment, about one half of people regain most or all of the weight they lost, and hormonal and other physical problems due to the disorder resolve. About one fourth improve some, gaining some weight back, but they may periodically return to their former eating habits (relapse). The remaining one fourth have frequent relapses and continue to have physical and mental problems due to the disorder.

Treatment

When weight loss has been rapid or severe—for example, to more than 25% below the ideal body weight—restoring body weight quickly is crucial. People with anorexia may need to be hospitalized to ensure that they consume enough calories and nutrients. Although eating food is the best treatment, people rarely need to be fed through a tube inserted through their nose and down their throat into their stomach (nasogastric tube). Doctors also check for problems due to anorexia nervosa, and any problems are treated. For example, if bone density has been lost, people are given calcium and vitamin D supplements and sometimes a bisphosphonate, such as alendronate, ibandronate, or risedronate. During hospitalization, psychiatric and nutritional counseling are provided. Hospitalization also helps by taking people out of their normal circumstances and disrupting their dysfunctional eating habits and behaviors. Thus, it may reverse a downhill course.

However, most people are treated as outpatients. Cognitive-behavioral therapy is usually used. Typically, therapy is needed for 1 year if people have regained the lost weight and up to 2 years if people are still underweight. This therapy is more effective for adolescents who have had the disorder for less than 6 months. Therapy is particularly important because most people with anorexia do not wish to be treated or to regain weight. Family therapy is useful with adolescents. It can improve interactions among family members and teach parents to help the affected adolescent regain the lost weight.

Treatment also involves seeing a doctor regularly for check-ups. It may involve a nutritionist, who may provide specific meal plans or information about the calories needed to restore weight to a normal level.

There are no specific drugs to treat anorexia nervosa. However, newer antipsychotic drugs, such as olanzapine, may help people gain weight and relieve their excessive fear of being fat. Selective serotonin reuptake inhibitors (a type of antidepressant), such as fluoxetine, may help prevent people who have regained weight from losing it again. They are particularly useful for people who also have depression.

Last full review/revision June 2008 by Albert J. Stunkard, MD