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Anorexia nervosa

Also listed as: Eating disorders - anorexia

• Signs and Symptoms
• Causes
• Risk Factors
• Diagnosis
• Preventive Care
• Treatment
• Other Considerations
• Supporting Research

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, or excessive exercise
• Binge-Eating/Purging Type (anorexic-bulimic) -- characterized by self-induced vomiting or misuse of laxatives, enemas, or diuretics. Binge eating may or may not occur, and purging (vomiting) 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 they are overweight.

Physical Signs

• Scanty or absent menstrual periods
• Thinning hair
• Dry skin
• Cold or swollen hands and feet
• Bloated or upset stomach

Psychological Signs

• Distorted perception of self (that is, a great difference between how an individual believes they look and their actual physical appearance)
• Inability to remember things
• Poor judgment
• Refusal to acknowledge the gravity of the illness
• Obsessive-compulsive behavior (excessive need to control personal environment)
• 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, and diminished interest in sex)

Behavioral Symptoms

• 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)
• Compulsive exercising
• Preoccupation with body size or body image
• Preoccupation with weight control, dieting

Causes

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 may include:

• 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 imbalances.
• A cultural environment that puts a high value on thin or lean bodies.
• Overbearing, controlling, and critical parents who do not show emotional warmth.
• 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 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 anorexia.

Risk Factors

• 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 disorder.
• 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 OCD tend to emerge before the eating disorder, while panic attacks may develop after the diagnosis is made.
• Avoidant or narcissistic personality disorders -- 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
• Dieting

Diagnosis

While your doctor will rely on points discussed in Signs and Symptoms -- such as excessive weight loss, refusal to maintain normal body weight, and distorted self-perception -- the doctor 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 disorder:

• S: "Do you feel sick because you feel full?"
• C: "Do you lose control over how much you eat?"
• O: "Have you lost more than 13 pounds recently?"
• F: "Do you believe that you are fat when others say that you are thin?"
• F: "Does food and thoughts of food dominate your life?"

If an eating disorder is suspected, the doctor will order several 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. Your doctor 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 doctor will require frequent office visits to monitor the condition. It is best for a person with anorexia to work with a multidisciplinary team including a doctor, a psychologist or psychiatrist, and a registered dietitian.

Preventive Care

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 and other physical signs by the health care 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.

Treatment

Anorexia demands a multi-pronged treatment plan that addresses both the physical and psychological aspects of this disorder. Cognitive-behavioral therapy, 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 herbs and 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. Hospitalization may be necessary, particularly under the following circumstances:

• Continuing weight loss, in spite of outpatient treatment
• Body mass index (BMI) -- BMI is a measurement that takes into account a person's height and weight) 30% below normal. The normal range is a BMI of 19 - 24.
• Irregular heart rhythm
• Severe depression
• Suicidal tendencies
• Low potassium levels
• Low blood pressure

Generally, adequate weight gain (1 - 2 pounds per week) and appropriate changes in behavior require a 10 - 12 week hospital stay. To avoid bloating, abdominal upset, and fluid retention, those who are severely malnourished are 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. Several social influences may make recovery difficult:

• Friends or family who express admiration or envy of the patient's thinness
• 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 also attractive and that purging is the only way to avoid becoming overweight

Involving 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.

Lifestyle

Treating anorexia nervosa involves major lifestyle changes. The person must not only alter eating habits but also adjust their 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.

Medications

Anorexia nervosa in some ways resembles other major psychiatric disorders, such as depression and obsessive-compulsive disorder, because people with anorexia exhibit 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). 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, may not work alone and should be used in conjunction with a multidisciplinary approach that includes nutritional interventions and psychotherapy.

Serotonin Reuptake Inhibitors

• Fluoxetine

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.

Tricyclic Antidepressants

This class of antidepressants, including imipramine and desipramine, tend to be more effective for bulimia than anorexia.

• Clomipramine

One study suggests that clomipramine has the potential to stimulate weight gain and improve symptoms of anorexia.

Antihistamines

• Cyproheptadine

In one study, using high doses of cyproheptadine hydrochloride, which is thought to stimulate appetite, decreased the number of days necessary to achieve appropriate weight gain and relieved depression in those with restricting type anorexia.

Hormones

Estrogen together with progesterone may help 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.

There are natural therapies, including dietary supplements, that may help the general health and well-being of a person struggling with anorexia to become more balanced. Always tell your health care provider about the herbs and supplements you are using or considering using, as some supplements may interfere with conventional treatments.

Following these nutritional tips may help reduce symptoms:

• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily. However, do not fill up on water only.
• Quality protein sources, such as organic meat and eggs, whey, and vegetable protein shakes, should be used as part of balanced program aimed at gaining muscle mass and preventing wasting. Talk with your health care provider about the best way for you to put on weight.
• Try to avoid refined sugars, such as candy and soft drinks.

You may address nutritional deficiencies with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-vitamins and trace minerals, such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil two to three times daily, to help decrease inflammation and improve immunity. Essential fatty acids play a critical role in brain function and hormone regulation, key health issues in the anorexic individual.
• Vitamin C, 500 - 1,000 mg one to three times daily, as an antioxidant and for immune support.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
• 5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization.
• Creatine, 5 - 7 grams daily, when needed for muscle weakness and wasting.
• Probiotic supplement (containing Lactobacillus acidophilus ), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. You should refrigerate your probiotic supplements for best results.
• L-glutamine, 500 - 1,000 mg three times daily, for support of gastrointestinal health and immunity.
• Dihydroepiandosterone (DHEA), start at 5 mg three times a day and work up to 100 mg per day for 7 - 12 months for hormonal effects. It is recommended to use DHEA under the supervision of a qualified health care professional. If adverse effects develop, discontinue use.
• Melatonin, 2 - 5 mg one hour before bedtime, for sleep and immune protection.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

• Ashwagandha ( Withania somniferum ) standardized extract, 450 mg one to two times daily, for general health benefits and stress.
• Fenugreek ( Trigonella foenum-graecum) , 250 - 500 mg two to three times daily, for appetite stimulation.
• Cayenne pepper ( Capsicum annuum ) standardized extract, 400 mg three times daily, for digestive stimulation.
• Milk thistle ( Silybum marianum ) seed standardized extract, 80 - 160 mg two to three times daily, for detoxification support.
• Fermented wheat germ extract, 1 packet dissolved in favorite beverage once daily, for immune effects and muscle gain.

Massage and Physical Therapy

Massage appears to be a helpful component of treatment for anorexia nervosa. Individuals using massage report lower anxiety levels and improved body image.

Homeopathy

A professional homeopath can provide supportive care to address various aspects of anorexia. Discuss homeopathy and anorexia with your health care provider.

Mind-Body Medicine

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 self-expectations.

Family Therapy

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. 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

Hypnosis has been reported to be successful as part of an integrated treatment program for anorexia nervosa. Hypnosis reportedly strengthens both self-confidence and the ability to cope, which may result in healthier eating, improved body image, and greater self-esteem.

Biofeedback

Studies suggest that biofeedback may be helpful in reducing stress in people with anorexia.

Other Considerations

Pregnancy

Anorexia poses several potential problems for women who are pregnant or wishe to become pregnant:

• Difficulty getting pregnant and 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 or parenthood

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)
• Increased cholesterol
• Hormonal changes (can lead to absence of menstrual periods, infertility, bone loss, and stunted growth)
• Osteoporosis
• Seizures and numbness in hands and feet
• Disorganized thinking
• Death (suicide is responsible for 50% of fatalities associated with anorexia)

The outlook for individuals with anorexia is variable, with recovery taking between 4 - 7 years. There is also a high chance of disease recurrence even after recovery. Long-term studies show that 50 - 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.

Supporting Research

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Escolar DM, Buyse G, Henricson E, et al. CINRG randomized controlled trial of creatine and glutamine in Duchenne muscular dystrophy. Ann Neurol . 2005;58(1):151-5.

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Gordon C, Grace E, Emans SJ, Goodman E, Crawford MH, Leboff MS. Changes in bone turnover markers and menstrual function after short-term oral DHEA in young women with anorexia nervosa. J Bone Miner Res . 1999;14:136-145.

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Holman RT, Adams CE, Nelson RA, et al. Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids. J Nutr 1995;125:901-907.

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• Review Date: 10/19/2006
• Reviewed By: Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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