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What is Anorexia Nervosa?

Anorexia nervosa, a severe eating disorder, includes periods of an individual depriving themselves of food and may involve alternating periods of compulsive eating (bingeing) and purgeing (bulimia nervosa), both of which are associated with other behavioural disorders not specified.

Doctors who diagnose individuals with anorexia nervosa do so when such individuals have a body mass index (BMI) and body weight much lower than their age, height and sex (a BMI below 18.5 is considered underweight and below 15 is severely underweight). In addition to food deprivation, this low body weight index may be due to the aberrant abuse of laxatives or diuretics, the generation of self-induced vomiting and strenuous exercise sessions in order to lose weight.

In all cases, individuals are not usually able to recognise their problem of extreme thinness, since they are not aware of their condition, categorically denying their health condition, and even isolating themselves from nearby people because they consider that they want to make them "fatten up".

This pathology is very rare before puberty and usually affects a more significant percentage of girls, although the age of onset is increasing and the rate of cases between both sexes is becoming more balanced. On average, anorexia nervosa is thought to appear around 17 years. The earlier the age of onset and the earlier its detection and treatment, the better the prognosis for recovery. Anorexia nervosa in individuals over the age of 40 it is infrequent, but it happens. Studies have established its prevalence as one case per 100 to 250 people.

Types of Anorexia Nervosa

There are two types of anorexia nervosa. Regardless of the type of anorexia nervosa developed, several studies have shown that individuals usually present with patterns of depression and anxiety (generalised anxiety disorder / social anxiety disorder (social phobia) prior to the development of the disorder, which remains or even increases throughout the mental illness and, in a significant percentage of individuals, persists once anorexia nervosa has been overcome, in particular, their depression.

Restrictive Anorexia Nervosa

This is a clinical situation where individuals achieve low weight through very restrictive diets, fasting, and abundant high-intensity exercise. These individuals do not resort to compulsive binge eating and subsequent purging.

Purgative / Compulsive Anorexia Nervosa

Individuals resort to punctual or systematic bingeing followed by purging (vomiting, laxatives, diuretics etc.). There is a subgroup that does not binge but does resort to purging in a systematic way. Due to the loss of impulse control, these individuals are more susceptible to greater emotional variability, as well as succumbing to the consumption of addictive substances (alcohol, tobacco, etc.).

Causes of Anorexia Nervosa

When looking for the causes of anorexia nervosa, it should be clarified that it is extremely difficult to establish common factors responsible for this eating disorder, mainly due to its psychological component and the great variation of signs and symptoms between individuals.

Studies have tried to determine the etiopathogenesis (origin of the pathology) of anorexia nervosa but they have not been conclusive, however, they point out some predisposing factors:

Individual Risk Factors for Anorexia

There has been discussions of a possible genetic component linked to the presence of the 5HT-2A gene detected in a large number of individuals diagnosed with this disorder and activated by malnutrition. Several twin concordance studies support this potential genetic component.

An increase in serotonergic activity (serotonin is a chemical in the brain) has been detected which seems to be closely linked to decreased food intake and behavioural disturbances. Anatomic and metabolic alterations have also been observed in subjects with anorexia nervosa, which could be related to the presence of the mental illness.

Finally, the presence of this mental illness has been predominantly related to psychiatric disorders such as major depression or obsessive-compulsive disorder (OCD).

Family Factors

The presence of alcoholism or psychiatric disorders in first-degree relatives (parents and siblings) have been related to the development of anorexia nervosa.

Cultural Factors

Unattainable canons of beauty imposed by society and an excessive worship of the body have also been related to the development of anorexia nervosa.

In addition to these factors, the initiation of restrictive diets is a precipitating factor of the eating disorder.

The Signs & Symptoms of Anorexia Nervosa

There are certain signs and symptoms that may make you suspect that an individual or yourself may be living with anorexia nervosa, however, diagnosis, treatment and follow-up should always be performed by a specialist healthcare professional.

Symptoms of Anorexia Nervosa

- A consistent feeling of unfounded obesity and a strong desire to continue to lose weight, with active control (looking at the mirror repeatedly, weighing yourself several times a day, counting calories, etc.)

- Low self-esteem

- Anxiety disorders with a tendency to depression and anxiety

Signs of Anorexia Nervosa

- Excessive weight loss in a short time

- Alterations of menstruation or absence of menstruation

- Performing constant and excessive physical exercise

- Avoiding meals

- Progressive isolation and loss of social bonds

- Obsession with the caloric content of everything consumed, taking only foods low in calories

- Uncontrolled use of diuretics and laxatives

- Dryness of the skin, with possibility of cracks

Clinical Signs of Anorexia Nervosa

In the clinical setting the main signs of anorexia nervosa are:

- The appearance of fine hair (lanugo) on cheeks, back, thighs and forearms

- Yellowish pigmentation on the skin, mainly on the soles of the feet and the palms of the hands. This is due to an increase in blood carotenes (precursors of vitamin A) because of a disorder in their metabolism

- Cold extremities

- Brittle nails and hair loss

- Hypertrophy of the salivary glands, such as the parotid glands and submandibular glands

- Dental alterations, with a tendency to the corrosion of the dental enamel and presence of caries. This is especially evident in patients who are purged through self-induction of vomiting

- Gastrointestinal disorders: flatulence, bloating, abdominal pain and constipation (except if laxatives are used that can cause diarrhoea that disrupts the electrolyte balance)

- Cardiovascular disorders: low blood pressure (hypotension), decreased heart rate (bradycardia), changes in the heart rhythm (arrhythmias), and so on

- Kidney disorders: indicative of a malfunction. Low potassium levels (hypokalemia), elevated levels of nitrogen-derived compounds (azotemia), and elevated serum creatinine levels can be found

- Hemogram: low levels of red blood cells (anaemia) and white blood cells (leucopenia)

- Biochemical levels: low glucose levels (hypoglycemia), increased triglycerides, transaminases and the general proteinogram, as well as cholesterol (hypercholesterolemia). If the patient also uses purgatives, enemas, or induces vomiting, there are other specific altered parameters.

The Diagnosis of Anorexia Nervosa

The diagnosis of anorexia nervosa is based on:

- An interview with you and a review of your medical and family history.

- A physical examination and evaluation of your heart rate, blood pressure and respiratory rate.

- Complementary clinical tests: hemogram, biochemistry, etcetera.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Society of Psychiatry, the four main diagnostic criteria for anorexia nervosa are:

1. A firm refusal to achieve and maintain a body weight equal to or greater than the normal minimum weight value considered on the basis of your age and height. Usually, the weight is less than 85% of the minimum corresponding to age and size

2. Pathological terror to weight gain and conversion into an obese person

3. Alteration of self-perception of body weight and body silhouette, with exaggeration of its importance in the capacity for self-evaluation, and negation of the risks associated with low maintained body weight

4. Amenorrhea in postpubertal women (disappearance of at least three menstrual cycles)

Keys to the Diagnosis of Anorexia

The 10th version of the International Statistical Classification of Diseases and Other Health Problems (ICD-10) maintains approximately the same diagnostic criteria for anorexia, although a little more extended, indicating:

- Significant weight loss achieved by avoiding "ingesting" foods, and two or more of the following symptoms: self-induced vomiting, use of laxatives, excessive physical exercise, use of diuretics, or appetite suppressants

- Specific psychopathology with an overrated and obsessive idea of horror towards weight gain, implying that the individual self-imposes an unwarranted low weight threshold

- Presence of disorders in the hypothalamic-pituitary-gonadal axis manifested in men as lack of sexual interest and impotence and, in women, as amenorrhea. There may be elevated levels of GH and cortisol, abnormalities in insulin secretion, and changes in the peripheral metabolism of thyroid hormone

Treatment of Anorexia Nervosa

Once the diagnostic parameters previously described have been evaluated, and other psychiatric and organic pathologies have been ruled out, you will be treated and followed up. The process of treatment of anorexia nervosa is multidisciplinary, requiring a coordinated action of your GP, a psychiatrist, psychologist, endocrine and gynaecologist for women. The main points of treatment are:

Modification of your eating habits: you will be "re-educated" with regards to your eating habits. To do this, it starts with a relatively low calorie diet (1,000-1,500 calories / day) and increases progressively until it reaches your natural caloric needs. Professionals should always respect your personal space so as not to pressure you, but not allowing you to eat alone, and ensuring that you meet your recommended daily intake of food.

Regular weight control: weekly increases of 250-500 grams should be detected by weighing you

Restriction of physical exercise: initially eliminated completely and reintroduced very progressively

Regular analytical controls to avoid organic complications

Pharmacological therapy: focuses mainly on the depressive or anxious component of anorexia nervosa. It is an individualised treatment and constrained to the requirements and your psychological situation

Psychological therapy: is used in an isolated, or combined, behaviour therapy, psychoanalytic, interpersonal and group therapy

Monitoring of the treatment of anorexia nervosa can be done in a combined way between the GP and the mental health unit. In the event that ambulatory follow-up has failed, and provided you have good family support, a good predisposition towards treatment and that you at least tolerate group therapy, therapy can be attempted in day hospitals, being a totally contraindicated option if you show a tendency toward suicide, substance abuse, or severe medical complications.

You may be hospitalised if there is a risk to your life, very serious psychological disturbance (suicide, other psychiatric disorders, etc.) or if your family situation is utterly unfavourable. Once treatment is started, the prognosis varies, although your capacity for early acceptance of this mental illness, the occurrence and short-term diagnosis of the eating disorder, good family support and absence are considered indicative of good prognosis (outlook).

The Prevention of Anorexia Nervosa

Early detection and getting help from specialists are the best weapons to combat anorexia nervosa once the mental illness has been established. However, it is better to prevent its occurrence with the handing out of health prevention and promotion programs in the family, educational and social fields, which hopefully will reduce the number of people who develop eating disorders whose consequences can irreversibly affect their health.

Preventing Anorexia in Adulthood

Here are some tips that will help you prevent anorexia nervosa during your adult years:

- Eat with family whenever possible, turning the meal into a pleasant meeting in which you exchange the experiences of the day

- The menus should be varied and include all types of foods needed for proper nutrition.

- Try different vegetables and fruits until you find the ones you like the most

- Set regular meal times. Better if the food is divided into four or five meals throughout the day (breakfast, lunch, lunch, snack and dinner)

- Boost your self-esteem. It is important that you know your abilities and limitations, and learn to feel comfortable with yourself. This will avoid future complexes

- Strengthen your autonomy and encourage yourself to have your own opinions and be less vulnerable to the messages of the media and advertising that convey the idea that having a perfect body is synonymous with success and happiness, forgetting the values of people.

- Try not to propose goals that exceed your abilities in order to avoid frustrations

- Encourage yourself to practice exercising regularly. It is good for your health and will help you stay in shape

- Try out having more social relations and your participation in social activities, excursions, cultural visits etc.

- Establish good communication with your friends and family so that you are able to seek their advice and help when faced with situations that are difficult or stressful

Related Conditions

Browse our resources on:

Bulimia Nervosa

Bipolar Disorder


Generalised Anxiety Disorder

Social Anxiety Disorder (Social Phobia)