Anorexia Nervosa

What is anorexia nervosa?

Anorexia nervosa (just called anorexia from now on) is an eating disorder. It means "loss of appetite due to your nerves". Anorexia is a serious condition which affects all sorts of people. Anorexia is very common – about 1 in 20 teenagers has it. However, it affects people of all ages and has become more common in boys and men in recent years.

People with anorexia often find that they do not allow themselves to feel full after eating. This means that they restrict the amount they eat and drink. People with anorexia are underweight. Sometimes, the weight becomes so low that it is dangerous to health.

How do I know if I have an eating disorder?

If you answer yes to two or more of these questions then you may have an eating disorder and you should see your doctor.

• Do you make yourself sick because you are uncomfortably full?
• Do you worry that you've lost control over how much you eat?
• Have you recently lost more than 6 kg (about one stone) in the past three months?
• Do you believe you're fat when others think you are thin?
• Would you say that food dominates your life?

What are the symptoms of anorexia nervosa?

Deliberate weight loss

This is the main symptom. You lose weight by avoiding fattening foods or even any foods. People with anorexia limit the amount they eat and drink to control how their body looks. You may often pretend to other people that you are eating far more than you actually are. You may be using other ways of staying thin such as exercising too much. You may also have made yourself vomit, take laxatives, or even take appetite suppressant drugs or diuretics (water tablets).

People with anorexia typically weigh 15% or more below the expected weight for their age, sex and height. The body mass index (BMI) is calculated by your weight (in kilograms) divided by the square of your height (in metres). For example, if you weigh 66 kg and are 1.7 m tall then your BMI would be 66/(1.7 x 1.7) = 22.8. A normal BMI for an adult is 20-25. Above that you are overweight, and below that you are underweight. Adults with anorexia have a BMI below 17.5.

With anorexia, you feel very in control of your body weight and shape. However, with time, anorexia can take control of you. After some time it can become very difficult to make healthy, normal choices about the amount and types of food you eat.

A wrong idea of body size

People with anorexia think that they are fat when they are actually very thin. Although other people see you as thin or underweight, it is very difficult for you to see this. You are likely to have a severe dread (like a phobia) of gaining weight. People with anorexia will do their utmost to avoid putting on weight.

Other features

It is common for people with anorexia to:

• Vomit secretly after eating.
• Try hard to hide their thinness, for example, by wearing baggy clothes.
• Tend not to be truthful about how much they eat and everything to do with food.
• Like food and feel hungry, but it is the consequences of eating that frightens them.

People with anorexia may also become obsessed with what other people are eating.

People with anorexia often restrict themselves to certain types of food. Eating food may even become like a ritual. For example, each time you eat you have to cut your food into very small pieces. You may think frequently about your weight and even weigh yourself most days or even several times a day. It is also common to feel cold most of the time and have irregular sleeping patterns. You might also find yourself having poor concentration.

What are the health risks with anorexia nervosa?

Health risks are caused by undereating (starvation) and by the methods used to get rid of eaten food (vomiting, excess laxatives, etc). Problems that may occur include the following:

Irregular periods

Many people with anorexia have irregular periods, as hormone levels can be affected by poor diet. Your periods may even stop altogether or you may find that your periods have never started, especially if you started having eating problems when you were younger. Some people with anorexia are even infertile (unable to have a baby).

Chemical imbalances in the body

These are caused by either repeated vomiting or excess use of laxatives. For example, a low potassium level which may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low calcium levels can lead to tetany (muscle spasms).

Thinning of the bones (osteoporosis)

This is caused by a lack of calcium and vitamin D and can lead to easily fractured bones.

Bowel problems

These may occur if you take a lot of laxatives. Laxatives can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation and also sometimes abdominal pains.

Swelling of hands, feet and face

This is usually due to fluid disturbances in the body.

Teeth problems

These can be caused by the acid from the stomach rotting away the enamel with repeated vomiting.

Anaemia

Having a diet low in iron can lead to anaemia. This can make you feel weaker and more tired than normal. Dizzy spells and feeling faint can also occur.

Depression

It is common to feel low when you have anorexia. Some people even become depressed which can respond well to treatment. It is important to talk about any symptoms of depression you may have. Many people find they become more moody or irritable.

Hair and skin problems

You may find you have downy hair on your body and also the hair on your head becomes thinner. Many people with anorexia also have dry, rough skin.

What is the cause of anorexia nervosa?

The exact cause is not fully understood. Part of the cause is a fear of getting fat but it is not just as simple as that. Different causes possibly work together to bring on the condition. These may include the following:

• The pressure from society and the media to be thin is thought to play a part. This is probably why anorexia is much more common in westernised countries.
• Personality and family environment probably play a role too. People with anorexia often have poor self-esteem (not much self-confidence) and commonly feel that they have to be perfectionists. Often there are disturbed family relationships. All sorts of emotions, feelings and attitudes may contribute to causing anorexia.
• There may be some genetic factor. We know this from studies of families with identical twins. If one twin has anorexia then the other has a 1 in 2 chance of getting it. This tells us that it has a tendency to run in some families and that the condition may have a genetic part. However, because not every twin gets it there are other factors too.

Are there any tests done for anorexia?

Although there is no test to diagnose anorexia, your doctor may wish to do some tests. These may include:

• Blood tests. These aim to check for complications of anorexia - for example, anaemia, kidney or liver problems or a low glucose level.
• Electrocardiography (ECG). This is a heart tracing which may show an irregular heart rhythm.

What is the treatment for anorexia nervosa?

The aim of treatment is to:

• Reduce risk of harm (and death) which can be caused by anorexia.
• Encourage weight gain and healthy eating.
• Reduce other related symptoms and problems.
• Help people become both physically and mentally stronger.

Most people with anorexia will be referred to a specialist mental health team. Members of the team may include psychiatrists, psychologists, nurses, dietitians and other professionals. If you have more severe anorexia you may be referred to a specialist eating disorder unit.

The sort of treatments that may be offered include the following:

Help with eating

Having regular meals is better. Even if you only eat small meals it is beneficial to the body to eat at least three times a day. You should try to be honest (with yourself and other people) about the amount of food you are actually eating. You should reduce the number of times you weigh yourself; try only to weigh yourself once a week. It may be useful to keep an eating diary to write down all the food that you eat.

Psychological ('talking') treatments

For example, cognitive behavioural therapy (CBT), cognitive analytic therapy (CAT), interpersonal psychotherapy (IPT) and focal psychodynamic therapy.Talking treatments help to look at the reasons why you may have developed anorexia, and aim to change any false beliefs that you may have about your weight and body, and to help show you how to identify and deal with emotional issues. Talking treatments take time and usually require regular sessions over several months. Treatment may also involve other members of your family going to meetings to discuss any family issues.

Antidepressant medication

This may be advised in addition to talking treatments if you also develop depression. These are not usually recommended if you are younger than 18 years old.

Treatment of any physical or teeth problems that may occur

This may include taking potassium supplements, having dental care and trying not to use laxatives or water tablets.

Self-help measures may be of benefit

There are a number of self-help books and guides available. These provide methods on how to cope with and overcome anorexia. (beat - the Eating Disorders Association listed at the end may be able to suggest current titles.) They are not suitable for everyone, particularly if your anorexia is severe.

Some people with more severe anorexia may need to have a short stay in hospital.

What is the outlook (prognosis)?

With treatment, anorexia can take weeks or even many months to improve. It can take several years for people with anorexia to become completely better. Many people find they still have issues with food, even after treatment, but they are more in control and can lead happier, more fulfilled lives.

Unfortunately, some people with anorexia die from causes related to anorexia. Causes of death include infections, dehydration, blood chemical imbalances (such as low potassium levels) and even suicide.

Further help and information

beat - the Eating Disorders Association

103 Prince of Wales Road, Norwich, NR1 1DW
Tel: 08456 341414 Web: www.b-eat.co.uk
Offers information and support.

Institute of Psychiatry/Maudsley Hospital

Web: www.iop.kcl.ac.uk/sites/edu/?id=131
This site has good information on medical complications of eating disorders and is kept up-to-date with research developments.

References

• Eating disorders, Clinical Knowledge Summaries (October 2009)
• Morris J, Twaddle S; Anorexia nervosa. BMJ. 2007 Apr 28;334(7599):894-8.
• Fenichel RM, Warren MP; Anorexia, bulimia, and the athletic triad: evaluation and management. Curr Osteoporos Rep. 2007 Dec;5(4):160-4. [abstract]
• Eating disorders, NICE (2004); Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders