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Anorexia nervosa (AN) is an eating disorder involving a severe limitation of food intake, intense fear of gaining weight, and disturbed or distorted body image. It can lead to devastating physical, psychological, and social consequences if left unaddressed.
Although it often involves significantly low body weight, it's essential to understand that anorexia nervosa can happen at any size, as the condition centers around the act of self-starvation, regardless of overall body weight.
The medical definition of anorexia nervosa is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM). This official list of all medically-recognized mental health conditions lays out certain criteria to help physicians distinguish cases of AN.
The most recent definition of anorexia nervosa includes the following considerations:1
Restriction of energy intake relative to requirements for age, sex, developmental trajectory, and physical health
Intense fear of gaining weight or persistent behavior to prevent weight gain
Recurring body image issues, including, a distorted view of one's body weight, shape, and/or size, significant influence of body weight or shape on self-worth, consistent lack of acknowledgement of low body weight
Early diagnosis and treatment of anorexia nervosa is essential to preventing permanent health damage and accelerating the recovery process. In fact, with proper treatment, many can make a full recovery from AN.
A medical provider with specialized training in eating disorders will complete a thorough examination of the patient. After consulting the DSM for the latest meaning of anorexia, the provider can then establish a diagnosis and suggest appropriate treatments based on the patient’s needs.
Medical professionals use a range of indicators to make a diagnostic determination.
In general, anorexia nervosa is characterized by a preoccupation with body shape, weight, and size. This preoccupation is usually disruptive to everyday life and one of the major drivers behind the disordered eating behaviors associated with AN.
Preoccupation with body image may appear as:2
Frequently weighing or measuring one's body
Frequently checking oneself in the mirror
Regularly airing concerns about "being fat" or desires to lose weight
Regularly comparing oneself to others, especially in terms of body shape or size
It's important to note that these concerns are not connected to actual body weight, shape, and size. While most people with AN present with low body weight, not every patient is underweight at the time of diagnosis. The common thread among them all is an altered perception of body weight.
Disordered eating behaviors
Many disordered eating habits are associated with AN. The severe limitation of food intake is the most common behavior, but anorexia nervosa can also present as:2
Rituals around food or eating, such as cutting food into tiny pieces
Rigid thinking around food or eating, such as staying away from entire food groups
Frequently skipping meals or denying hunger
Only eating from a small group of "safe" foods
Some subtypes of AN also involve binging and purging behavior, similar to those seen with bulimia nervosa (BN). Purging behaviors in these cases can include excessive exercise, laxative abuse, use of enemas, or self-induced vomiting.2
Physical assessment
A thorough medical history and physical examination of patients with suspected eating disorders can reveal signs of malnutrition and other related health conditions. While these don't necessarily point to AN, they are often indicative of extreme eating behaviors.
A doctor will frequently do a visual inspection of hair, skin, nails, knuckles, and teeth. Many of these areas are commonly affected by AN. Providers also assess vital signs like blood pressure, pulse, temperature, and respiration rate to help make an official diagnosis.
Laboratory values
Blood tests provide other valuable insights about the health status of patients who engage in restrictive eating behaviors. Low blood counts often indicate inadequate nutrition, compromised immune function, and impaired metabolism. They can also detect related medical conditions and risk factors, such as dehydration and vitamin deficiencies.
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Signs & symptoms of anorexia nervosa
Eating disorders can be elusive, and the subtle nuances between the different types of eating disorders can also make them difficult to diagnose. Identifying the signs and symptoms of anorexia nervosa is therefore a critical part of getting a proper diagnosis.
Behavioral signs of anorexia
A few warnings signs that could reveal anorexia nervosa include:2
Avoiding eating in public or in front of others
Expressing feelings of guilt after eating
Lying about the amount of food consumed
Wearing baggy clothing to disguise one's body
Cooking elaborate meals for others but not partaking in eating them
Social withdrawal or isolation
Physical signs of anorexia
Anorexia nervosa also manifests in a number of physical ways. Some physical signs of the condition include:2
Anorexia nervosa can cause a number of both short-term and long-term medical complications.
Short-term effects
In the short term, the effects of anorexia nervosa are more subtle. Significant weight loss is among the most common, and obvious, impacts.
Electrolyte imbalances are usually an early effect of AN, along with blood pressure changes and signs of dehydration. And many people who engage in disordered eating also experience gastrointestinal distress, including bloating, abdominal pain, and constipation.2
However, if left untreated, these issues can get worse. Electrolyte imbalances can even become deadly. And AN can go on to cause other issues, as well.
Long-term effects
The long-term effects of anorexia nervosa are more devastating. The restriction of calories and lack of nourishment over extended periods of time impacts nearly every organ system and internal bodily function.
Some of the most serious long-term effects of this type of include:2,3
Loss of bone mineral density (osteoporosis)
Loss of muscle (cachexia)
Irregular or absent menstrual cycles in women (amenorrhea)
Without a clear understanding of eating disorders such as anorexia nervosa, people often make generalizations that lead to inaccurate assumptions and judgments. For example, anorexia nervosa is not a lifestyle choice, as many people think; it is a complex medical and psychological condition that requires professional treatment.
Another common misconception is that AN only affects women, and particularly young white women. In fact, anorexia nervosa affects people of all gender identities, sexualities, races, ages, and ethnicities.
As many as one in four people diagnosed with anorexia nervosa identify as male.4 More broadly, research compiled on a range of disordered eating behaviors find these conditions often affect people of color, members of the LGBTQIA+ community, people with disabilities, and people in larger bodies just as much, if not more, than white females.12,13
Part of the misrepresentation issue may come from the research itself. A majority of medical studies to date have focused on white females, failing, in many cases, to include other genders or ethnicities in their samples. This can then impact the way doctors think about the conditions and influence, subliminally or not, the patients they decide to screen for eating disorders.
Anorexia risk factors
Though AN impacts people across the board, a number of risk factors make certain people more likely to develop the condition. Some identified risk factors include: (8)
Family history of AN or other eating disorders
A history of trauma or exposure to adverse events
Low self-esteem
Substance abuse
Certain personality traits, including, perfectionism, obsessionality, excessive compliance
Anorexia and co-occurring disorders
In a vast majority of cases, anorexia nervosa occurs alongside other mental or physical disorders. In fact, one recent study found that anywhere from 55% to 95% of people with eating disorders will experience a co-occurring psychiatric disorder in their lifetime.10
Some of the most common comorbid, or co-occurring, disorders with AN include:16
Anxiety disorders, including social anxiety
Major depressive disorder
Obsessive compulsive disorder (OCD)
Post-traumatic stress disorder (PTSD)
Substance use disorders (SUDs)
Borderline personality disorder
Comorbid conditions can either arise from anorexia nervosa, or predate the condition and contribute to its development. In either case, comorbid conditions often become deeply interwoven and wind up driving or maintaining one another.
A number of therapeutic approaches and care options have worked to help people recover from AN.
The most effective treatment programs are individualized, based around a patient’s unique medical needs, behaviors, and challenges. Interdisciplinary treatment teams are also an essential component in addressing the various physical, mental, and emotional complications involved in anorexia nervosa.
Consisting of healthcare professionals with specialized knowledge in a range of topics, a comprehensive clinical care team should include (at minimum):
A physician
A mental health professional
A registered dietitian/nutritionist
In addition to the core medical team, family and friends also play a vital role in the healing process. By offering additional support and encouragement, these loved ones can help patients achieve better outcomes, both throughout the treatment process and during a sustained recovery.
There are several levels of care for the treatment of anorexia nervosa. Generally, these programs are based on symptom severity, with a patient moving between levels as progress continues. They include:
Inpatient Hospitalization: This is the most intensive level of treatment. It’s required for anyone experiencing a physical or mental health crisis—such as severe malnutrition, suicidal ideation, or other complicating co-occurring conditions—which prevents them from entering other levels of care.
Residential Treatment: This type of treatment is generally received at a clinic or treatment center. Patients live and sleep at the facility, follow intensive treatment schedules, and have access to 24/7 medical care.
Partial Hospitalization (PHP): PHP is for people who still require a high degree of support, but who are ready to start living at home. Patients commute to treatment, generally between 4-8 hours per day, up to 5 days per week, but sometimes more. It's pivotal at this stage for someone to display the ability to make better decisions at home without 24-hour supervision.
Intensive Outpatient (IOP): IOP is a step down from PHP, a true middle-ground phase of treatment, for patients who are ready to start adding social responsibilities like work and school back into their daily routines. It usually includes attending a treatment clinic a few days per week, for up to a few hours.
Outpatient (OP): Outpatient treatment is the least-intensive form of care of AN. It typically includes attending individual therapy sessions (typically 1-2 times per week) and is best for people with minimal symptom severity or those in recovery.
Therapies for anorexia nervosa
Many therapeutic methods can be used to help people with anorexia nervosa, including:
Cognitive behavioral therapy (CBT):Cognitive behavioral therapy is a common form of psychotherapy that helps patients with anorexia nervosa connect their disordered thoughts with their disordered behaviors. This type of therapy focuses on identifying triggers and changing the corresponding responses.
Dialectical behavioral therapy (DBT): Dialectical behavioral therapy operates off the idea that patients can simultaneously love and accept themselves, and work on improving themselves. In this regard, it helps teach patients skills for greater emotional regulation, to give them better responses to triggering thoughts.
Acceptance and commitment therapy (ACT): Rather than focusing on changing disordered thoughts, acceptance and commitment therapy asks patients to let them go. Instead, patients are advised to use that energy toward participating in healthy activities that align with their goals and morals.
While these are some of the most common therapeutic methods for treating AN and other eating disorders, they are not the only options. Additional approaches include:
Within Health's treatment options for those struggling with anorexia nervosa are catered to the severity of the condition and the overall health of the individual seeking treatment. The most important thing to understand is that, no matter the condition, eating disorders are treatable.
86%
of those who complete our treatment program report reduced eating disorder symptoms
Currently, there is no FDA-approved medication specifically targeted to treat anorexia nervosa. However, there are several types of medication approved to treat anxiety, depression, and other common co-occurring conditions.
A doctor may choose to prescribe these medications for someone struggling with AN. Each case is different and depends on a number of individual factors, including someone’s health history and the severity of their symptoms, among other considerations.
Barriers to treatment
Anorexia nervosa is a dangerous and potentially deadly condition. It generally doesn't get better on its own and only gets worse over time, making treatment key. Yet, it's thought that as much as 75% of people with an eating disorder aren't accessing appropriate care.10
There are numerous potential barriers to treatment, spanning everything from insurance issues to social stigma around the conditions and seeking out help. Some comorbid conditions may also impact someone's motivation levels or ability to schedule appointments.10
Many people see AN as a modern phenomenon, but the condition has been noted throughout the course of history:
Middle Ages: Self-induced starvation was first recorded, when some religions viewed extreme fasting as a sign of beauty and reverence.5
1689: Dr. Richard Morton recorded the first notes about “nervous consumption,” a term he used to describe patients with poor appetite and weight loss. It may be the first anorexia definition.6
1873: The term “anorexia nervosa” was first used to describe the condition.19
1952: Anorexia nervosa was officially listed in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), cementing the first anorexia medical definition.
Still, since the DSM included its first anorexia definition, there's been a rise in noted cases. Some health experts believe this is connected to the bombardment of societal messaging around appearance.7 The rise of social media and its ability to quickly spread these messages is also considered by some a reason behind the uptick in disordered eating behavior among certain populations.9
More recently, the COVID-19 pandemic seems to have influenced these numbers. The National Eating Disorder Association (NEDA) said during the first years of the pandemic, calls to their helpline were up as much as 107%, eclipsing 70,000 calls per year.17
Still, organizations like Health at Every Size (HAES) have been trying to combat these statistics, spreading the message of embracing self-love, acceptance, and joy, no matter what your body weighs.
How to help someone with anorexia nervosa
Anorexia nervosa is a dangerous and potentially deadly condition. Early treatment is critical if you or someone you know is experiencing signs of AN.
The first step in the recovery process is speaking with a trusted healthcare professional, like your primary care physician or therapist. They can help you secure an official diagnosis and write referrals to specialists or other treatment programs.
You can also seek out treatment through other avenues. Online therapy is growing in efficiency, prevalence, and acceptance all the time, and studies have shown that virtual care can be just as effective as in-person treatment in many cases.18
At Within Health, we strive to offer the best of that online experience, putting you in touch with a personal care team who will develop an individual treatment plan that you can follow all without having to leave your home.
Regardless of where you look, the most important thing you can do is seek help. It often is the pivotal first step on a journey toward healing and happiness.
Remote care is within reach
Within Health offers compassionate, highly-personalized treatment programs for people with eating disorders. Call our admissions team today to learn how we heal anorexia nervosa.
Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.
Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.
Eddy, K. T., Tabri, N., Thomas, J. J., Murray, H. B., Keshaviah, A., Hastings, E., Edkins, K., Krishna, M., Herzog, D. B., Keel, P. K., & Franko, D. L. (2017). Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. The Journal of Clinical Psychiatry, 78(2), 184–189.
Anorexia nervosa isn't caused by a single factor, but likely by a multitude of factors. Genetic, biological, physiological, and environmental circumstances can all play a part in the development or maintenance of the condition.
Some of the most common causes are heritability (having a relative with an eating disorder), a history of trauma, and chronic low self-esteem.
Is anorexia an addiction?
No. While some behaviors involved with AN do parallel those associated with addiction—including the fixation and prioritization of certain behaviors to the point of disruption to everyday life—ultimately, the two conditions are fundamentally different.15
How many patients with anorexia nervosa fully recover?
Recovery from anorexia nervosa is often a lengthy process, and the journey is rarely a straight line. Those who go through it may frequently encounter setbacks, but a majority of those who stick with it will find recovery in time.
One of the longest-term looks at eating disorder recovery found that, at 9 years post-diagnosis, approximately one-third of patients with AN had achieved recovery. By 22 years post-diagnosis, that number had reached nearly 63%.11
Where can you find help for a loved one when you suspect they have anorexia nervosa?
Contact the clinical care team at Within Health to learn more about resources available in your area.
Get access to a streamlined experience with our industry-first treatment app. You can attend individual and group sessions, connect with your care team, submit weights and vitals via a numberless scale provided to you, receive meal support, and access check-ins and recovery-focused tools for use between sessions.
