Anorexia nervosa is a serious mental health condition and is one of the three major eating disorders. Anorexia nervosa is defined by an extremely low body weight with intense fear of weight gain that makes sufferers follow a restricted diet.

There are two familiar types of anorexia nervosa, which are restricting and purging. In the restricting type of anorexia nervosa, patients tend to lose weight through restricting they calorie intake, whereas in the purging type of the condition, patients tend to use self-induced vomiting or laxatives and diuretics to prevent weight gain.

A combination of multiple risk factors can increase a person’s susceptibility to anorexia nervosa, including non-modifiable risk factors such as gender, age, genetics and family history, and modifiable risk factors such as alteration in body weight, poor body image, the impact of media and society, perfectionism, history of anxiety disorders, feeling lonely and isolated, being discriminated against, and work in sports, art, or modeling.

Signs and symptoms related to anorexia nervosa are divided into purging, food and eating behavior, and body image symptoms. Purging symptoms include consuming laxatives, diet pills, or diuretics, self-induced vomiting after eating, and compulsive exercising. Food and eating behavior symptoms include following a restricted diet even when the patient looks thin, obsession with counting calories and fat grams, pretending to eat, worrying about food, and strange or secretive food rituals. Body image symptoms include rapid weight loss, having a slim body while permanently feeling obese, obsession with body image, and never feeling satisfied about body weight.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) sets the diagnostic criteria for anorexia nervosa to include: restriction of energy intake relative to requirement, having significantly low body weight, intense fear of gaining weight, persistent behavior that interferes with weight gain, disturbance in the way in which the patient views his or her body weight or shape, self-evaluation that is influenced by body weight , and\or not recognizing the dire effects of the current low body weight.

Generally, the pathophysiology of anorexia nervosa disorder is indefinite. It was proposed that a defect in negative feedback control mechanisms, which can cause an increase in dopamine activity, play a role in the pathophysiology of anorexia nervosa.

There are many methods commonly used to treat patients with anorexia nervosa including psychotherapy, medications and hospitalization. Psychotherapy may involve several types of therapy that mainly aim to convince and encourage patients to practice healthily eating behaviors.

Good treatment programs can help patients with anorexia nervosa to recover and return to their healthy weight, but the condition can be life threatening if left uncontrolled.

According to the National Eating Disorders Association, anorexia nervosa is the third most common chronic disease among young people. Young people between the ages of 15 and 24 with anorexia have 10 times the risk of dying compared to their same-aged peers.

Anorexia is a potentially life-threatening eating disorder characterized by extreme and unjustified weight loss accompanied by intense fear of weight gain; these factors lead sufferers to severely restrict the amount of food they eat, or follow purging procedures, such as induced vomiting, to maintain their extremely low weight.

Anorexia nervosa is classified into two main subtypes:

Restricting type

Patients with anorexia nervosa of the restricting type achieve weight loss by restricting calorie intake by following restricted diets, fasting, and exercising excessively.

Purging type

Patients with the purging type of anorexia nervosa achieve weight loss by taking measure to counteract their calorie intake. Purging measure include self-induced vomiting or consuming laxatives and diuretics.

The exact cause of anorexia nervosa is unknown. A combination of many biological, psychological, and environmental factors can lead to developing the condition.

There are many factors that may increase the risk of getting anorexia nervosa, such as:

• Gender

Being female increases the risk of developing anorexia nervosa. Nevertheless, social stressors may increase the risk of developing anorexia nervosa in males.

• Age

People at any age are susceptible to develop anorexia nervosa, but, adolescents are most susceptible to getting the disorder.

• Genetics

Mutations in certain genes may make certain people more at risk of developing anorexia nervosa.

• Family history

Individuals who have first-degree relatives with anorexia nervosa are more likely to develop it themselves.

• Alteration in body weight

People who lose weight for certain reasons may receive praise for their new weight, which may encourage them to maintain this low weigh or reduce it further. 

• Media and society

The media in all its different forms, such as TV and fashion magazines, imposes the ideal body image and its relation with individual success, which in turn puts individuals under great psychological pressure that can increase the probability of getting anorexia nervosa.

• Work in sport, art, or modeling

Working in these fields can increase the risk of getting anorexia nervosa, since they require those involved to maintain an ideal body weight.

• Looking for perfectionism

Perfectionism represents one of the greatest risk factors for developing anorexia nervosa. Self-oriented perfectionism is a type of perfectionism that may push people to anorexia nervosa in a bid to maintain what they see as the perfect weight or body shape.

• Poor body image

Usually, people who dislike their appearance tend to have a high risk of developing anorexia nervosa.

• History with anxiety disorders

Research has found that many people with anxiety disorders, such as social anxiety disorder, are more at risk of developing anorexia nervosa.

• People who suffer from discrimination

They are at risk of developing anorexia nervosa.

• Feeling lonely and isolated

Individuals who feel that they are alone, maybe because they have fewer friends and social activities, are at an increased risk of getting anorexia nervosa.

Generally, the pathophysiology of anorexia nervosa is not fully determined. It was proposed that a defect in negative feedback control mechanisms play a role in the pathophysiology of anorexia nervosa as these defects can cause an increase in dopamine activity.

A defect suggested is that patients with anorexia nervosa experience negative feelings as a response to increased dopamine concentrations. Therefore, eating, which usually releases dopamine to give a feeling of satisfaction, is associated with negative emotions in patients with anorexia nervosa.

Another defect suggested by a group of scientists looking into the dopamine levels in patients with anorexia nervosa and its relation with restricting calorie intake or fasting is that people with the disorder tend to feel satisfied when they severely limit their calorie intake and not when eating. Hence, the more one restricts, the more dopamine is released and the more satisfied they feel, which further anchors the restricting behavior.

Signs and symptoms that appear on a person who suffers from anorexia nervosa are divided into three categories. Symptoms include:

Purging

• Using laxatives, diet pills, or diuretics

Excessive use of drugs such as water pills, laxatives, herbal appetite suppressants, prescription stimulants, ipecac syrup in order to lose weight.

• Self-induced vomiting

People with anorexia nervosa go straight to the bathroom after eating to get rid of the food they eat. They often use sounds to cover the sound of vomiting, such as running the water faucet.

• Compulsive exercising

The person with anorexia nervosa attempts to burn the calories they ate by exercising hard even when they should not because of an injury or illness.

Food and eating behavior

• Following a restricted diet

Patients with anorexia nervosa refuse eating the normal quantity of food, and they prefer low-calorie foods with no carbohydrates and fats even when their weight is dangerously low.   

• Obsession with calorie count

Patients with anorexia nervosa show an anxiety-inducing obsession in measuring and weighing food portions to calculate calories and fats.

• Pretending to eat

Patients with anorexia nervosa tend to make excuses to skip meals, and try to hide the fact that they did not eat by hiding or throwing away food.

• Always worried about food

Anorexia nervosa sufferers may find themselves constantly preoccupied with thoughts about food.

• Strange or secretive food rituals

Patients with anorexia nervosa prefer to eat alone and they refuse eat in public places. 

Body image

• Rapid weight loss

Without the presence of any other medical cause, patients with anorexia nervosa lose weight rapidly.

• Low weight but feeling obese

Patients with anorexia nervosa have a constant sense of excess weight in their entire body or in certain places, such as the stomach, hips, or thighs despite being very slim.

• Obsession with body image

Patients with anorexia nervosa usually show an obsession about weight, body shape, or clothing size.

• Never feeling satisfied about body weight

Patients with anorexia nervosa are usually always trying to lose more weight, even when their current weight is dangerously low.

Mental health professionals usually use the DSM-5 diagnostic criteria to diagnose anorexia nervosa. Diagnostic criteria for the disorder include:

• Restriction of energy intake relative to requirement, causing a significant reduction body weight compared to others of the same age, sex, developmental trajectory, and physical health.
• Exaggerated fear of gaining weight or becoming fat, or constantly behaving in a manner that would interfere with and prevent weight gain, despite that the patients weight is significantly low.
• Disturbance in the way patients experience their weight or shape is experienced, self-evaluation that is markedly influenced by body weight or shape, or a constant lack of recognition that their low weight poses a great threat to their health and wellbeing.

Convincing patients with anorexia nervosa that they have an illness and must be treated is the biggest challenge in the treatment of anorexia nervosa. Treatment usually involves:

Hospitalization

It is recommended to begin the treatment of anorexia nervosa with a short stay in the hospital.

In certain cases, patients may need to stay in the hospital for longer time, these cases include:

• Severe and life-threatening malnutrition

Patients who have lost more than 70% of their ideal body weight may need intravenous or stomach tube. 

• Continuous weight loss

Patients who have continuous weight loss even with treatment need to stay in hospital.

• Medical complications

Patients with serious medical complications such as low blood levels of potassium, heart problems, or confusion need to stay in hospital.

• Severe depression

Patients who suffer from severe depression and have suicidal tendencies need to stay in hospital.

Fixing dietary habits

This involves correcting patients’ wrong eating habits and helping them restore normal body weight, where they work on increasing weight by 0.5 to 1.5 kg per week.

Psychotherapy

Psychotherapy is used in case of anorexia nervosa to convince patients and encourage them to practice healthily eating behaviors. This type of therapy is effective in treating adolescents with anorexia nervosa. Psychotherapy may include:

• Cognitive analytic therapy (CAT)

This type of psychotherapy is based on the theory that mental health conditions, such as anorexia, are caused by unhealthy patterns of behavior and thinking developed in the past, usually during childhood.

CAT includes a three-stage process:

• Reformulation

Looking for reasons of unhealthy patterns in the past events which can explain these patterns.

• Recognition

Helping people see how these patterns are contributing towards anorexia nervosa.

• Revision

Determine ways to eliminate these unhealthy patterns.

• Cognitive behavioral therapy (CBT)

CBT is based on the theory that our actions, including eating, are affected by what we think and feel. Therapists here try to show how anorexia nervosa is often associated with unhealthy and unrealistic thoughts and beliefs about food and diet.

• Interpersonal therapy (IPT)

IPT is based on the theory that mental health is affected by people’s relationships with others around them and the outside world.

Issues that result from interaction with surrounding people, such as feelings of low self-esteem, anxiety and self-doubt, may make people are more susceptible to get anorexia nervosa.

The therapist conducting IPT will discuss problems associated with their patients’ interpersonal relationships and how to deal with them.

• Focal psychodynamic therapy (FPT)

FPT is based on the theory that the previous unresolved conflicts, especially during childhood, can affect the individuals’ mental health.

The therapist in FPT helps the patient find successful ways to cope with stressful situations and negative thoughts and emotions. Moreover, the therapist will encourage patients with anorexia to think about how early childhood experiences may have affected them.

• Family interventions

Families of adolescents with anorexia have a significant impact on them, and family intervention is a critical part of treatment for this group of sufferers because they lack control over this serious condition, and they are unable to make good eating choices.

Medications

Psychiatric medications used in treating other mental disorders may be helpful in treating anorexia nervosa. Two main types of medication can be used to treat patients with anorexia nervosa:

• Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are a type of antidepressant medications. They may be used to help anorexia nervosa patients who have a co-existing psychological problem such as depression or anxiety.

• Olanzapine

Olanzapine is an antipsychotic medication used mainly to treat schizophrenia, but it may be prescribed for patients with anorexia nervosa who did not respond well to other treatments and have feelings of anxiety related to weight and diet. 

Patients with anorexia nervosa may suffer from physical and mental complications:

Physical complications

• Low blood pressure and heart issues such as slow heartbeat and damage to the heart’s structure and function, which in turn increases risk of heart failure and death.
• Osteoporosis or a milder form of bone density loss called osteopenia.
• Amenorrhea which is the absence of the menstrual cycle in females.
• Reduced testosterone in males.
• Electrolytes imbalance, such as such as low blood levels of potassium, sodium and chloride.
• Severe dehydration which can lead to problems such as kidney failure.
• Gastrointestinal problems, such as severe constipation, bloating or nausea.
• Muscle loss and anemia which can lead to fainting, fatigue, lethargy, shortness of breath, increased infections, heart palpitations and overall weakness.
• Dry and brittle skin, hair and nails, in addition to hair loss.
• Edema (swelling).
• Delayed sexual growth if the patient is in the prepubertal age. 
• Growth of lanugo which is a soft and fine layer of hair produced by the body to warm itself as a result of drop in internal body temperature.
• Infertility, increased rates of miscarriage and other fetal complications.  

Mental complications

• Mood disorders, such as depression and anxiety.  
• Personality disorders.
• Obsessive-compulsive disorders.
• Misuse of alcohol or drugs.
• Suicidal tendencies.

There is no direct way to prevent people from getting anorexia nervosa. However, identifying its early indicators can possibly prevent the development of the disorder. Prevention is divided into primary and secondary, each having different aims:

Primary Prevention

This aims to eliminate the risk factors that increase the risk of anorexia nervosa. Measures include:

• Reducing Social Stresses

Many plans can be developed to decrease the impact of social stresses, particularly pressures on women to get be at a perfect weight.

Children must be taught not to be obsessed with their weight, by accepting the wide variety of body sizes and focus on the personality of individuals and not on their external appearance. Schools must also carry out ideal prevention programs because adolescent girls are at a high risk for developing anorexia nervosa.

• Reducing Family Problems

Parents should learn more about anorexia nervosa so that they would be able to spot any alterations in their children’s weight and eating behaviors which may indicate the disorder. Additionally, family members should be careful about their attitude around food, weight and body shape so as not to negatively influence their children’s views of such issues.

• Reducing Individual Factors

The way family members interact with one another and the wider cultural values can negatively affect individuals and make them less respectful of themselves and constantly seeking perfectionism. It is hard to change family relations and social forces, but individuals should be encouraged to seek advice on how to deal with low self-esteem, feelings of ineffectiveness or other issues. Parents have a chance to educate their children on how to respect and love themselves.

Secondary Prevention

Secondary prevention measures aim to spot anorexia nervosa early and decrease its duration. Secondary prevention involves:

• Family and peers

People around those at risk of anorexia nervosa can observe changes in their weight and diet habits, so having a good relationship with people who are at risk can help in preventing the disorder.

• Educators

Usually, teachers spend a lot of time with adolescents and young adults, and they usually have a more objective picture of student behavior and attitude changes, so they have a good chance to identify developing anorexia nervosa.

• Health Care Professionals

People who work in health care can be the first to detect anorexia nervosa. Doctors can note symptoms of weight loss, digestive problems and amenorrhea. Dentists can note symptoms of purging behaviors, such as erosion of the teeth and enlargement of salivary gland.

Anorexia is a critical condition that can be life-threatening if left uncontrolled. The US National Eating Disorders Association (NEDA) says that young people between the ages of 15 and 24 with anorexia nervosa have 10 times the risk of dying compared to their same-aged peers.

Nevertheless, good treatment programs can help patients with anorexia nervosa recover and restore their healthy weight, but recurrence of the disorder is quite common.

Usually, people who had anorexia nervosa will continue to prefer a lower body weight and be focused on food and calories. It may be hard for patients to manage weight, so long-term treatment may be needed to maintain a healthy weight.

In severe malnourished anorexia nervosa patients, body organs may have sustained irreversible damage, causing long term effects even after the disorder is controlled.

According to NEDA, anorexia nervosa is the third most common chronic disease among young people, preceded only by asthma and type 1 diabetes. A study published in the American journal Current Opinion in Psychiatry shows that the incidence of anorexia nervosa has increased over the last 50 years in females between the ages of 15 and 24, but the incidence did not change in other age groups and in males.