Anorexia Nervosa

What Causes Anorexia Nervosa?

Over the years, anorexia nervosa has been viewed primarily as a psychiatric diagnosis. Childhood trauma can linger into adulthood, often with devastating emotional consequences. Victims of childhood sexual abuse often suffer from anorexia nervosa, along with post-traumatic stress disorder (PTSD), panic attacks, and self-destructive behaviors. They learn silence, secrecy, and shame.

About half of people with anorexia nervosa also have other mental health issues, such as an anxiety disorder, obsessive-compulsive disorder, or social phobia. A third to half may suffer from a mood disorder like bipolar disorder or depression. Alcohol abuse and drug addiction are common in people who suffer from anorexia nervosa and other eating disorders. Mental health therapies are part of the process of recovery from eating disorders.

People with anorexia nervosa often:

• Spend a lot of time thinking about food and calories.
• Run their lives according to strict rules about eating.
• Skip meals and avoid eating in public.

Retraining the brain to develop a healthy attitude toward eating is vital to recovery from anorexia. It’s essential to get treatment because people with anorexia nervosa can get seriously ill — or even die — from the disorder.

Scientists continue to explore the behavioral, psychological, and cultural factors that influence anorexia nervosa. Although the disorder’s roots remain elusive, researchers suspect that genetics plays a role in more than half of cases [see Genetics].

Warning signs of anorexia nervosa include:

• Focus on weight and morbid preoccupation with dieting
• Secrecy, rituals, and odd behaviors related to eating habits, such as cutting food into tiny pieces or pushing it around the plate
• Excessive exercise
• Wearing oversized or baggy clothes to disguise weight loss
• Noticeable personality changes and social withdrawal

People with anorexia nervosa often deny that they have a problem. They don’t want to gain weight, so they reject help.

Is Anorexia Nervosa Hereditary?

A new understanding of the role of genetics in eating disorders is bringing hope to the families of people who are diagnosed with life-threatening anorexia nervosa.

For decades, anorexia nervosa was considered to be the direct result of family stress and peer pressure. In the popular imagination, risk factors for anorexia nervosa include being young, female, having an overachieving personality, and dysfunctional family dynamics. Today, doctors understand that eating disorders occur in all types of families.

Research suggests that genetic factors influence who is vulnerable to the disorder. Although experts think 50-80% of cases result from genetics, no specific gene has yet been linked to the condition.

While anorexia nervosa tends to run in families, the disorder results from multiple factors. Studies of genes at the molecular level have not pinpointed any DNA variants that directly cause anorexia nervosa. However, a recent gene sequencing study at the University of Iowa identified previously unobserved and ultra-rare mutations that appear to influence anorexia nervosa and other eating disorders. Scientists think the condition may result from a genetic predisposition triggered by life events and the family environment.

How Is Anorexia Nervosa Detected?

Symptoms of anorexia nervosa usually appear in adolescence. The average age of onset is 17. Rarely, children under the age of 10 or women in their 30s develop the disorder. Peer pressure, identity issues, and family stresses often seem overwhelming as teens move from childhood into adolescence. Cultural stereotypes about beauty and body shape influence young people in not-so-subtle ways.

The most common signs of anorexia nervosa include weight loss, excessive exercise, preoccupation with body weight, and the irrational fear of becoming fat. Many young women with anorexia nervosa stop having periods. People with anorexia nervosa often hide their weight loss by wearing loose clothes and lying about how much food they have consumed.

How Is Anorexia Nervosa Diagnosed?

While there is no test to diagnose anorexia nervosa, a physician may suspect an eating disorder based on an individual’s abnormal weight. Healthy adults usually have a body mass index (BMI) of between 18.5 and 24.9. Anorexia is diagnosed in an otherwise healthy adult whose BMI falls below 17.5. Severe malnutrition is diagnosed in people whose BMI is lower than 15.

The following tests can help diagnose anorexia nervosa:

• Blood tests reveal abnormal nutrient levels. As someone recovers from anorexia nervosa, blood tests track nutrient values as they return to normal levels.
• An electrocardiogram (EKG) records the electrical activity in the heart and measures heart rate and rhythm.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Anorexia Nervosa Treated?

Treatment for anorexia nervosa is a multidisciplinary process. With treatment, about 60% of people with anorexia nervosa make a full recovery. Another 20% make a partial recovery but remain very focused on food and weight.

Medical treatment

In consultation with the doctor, a dietitian (food and nutrition expert) creates meal plans to help people gain weight safely. Most people work with a team that includes a mental health clinician, dietitian, and medical support.

Slow, steady weight gain is vital because “refeeding syndrome” is a potentially life-threatening complication of anorexia nervosa. The risk of developing complications is greater when significant weight loss is followed by rapid weight gain. The body’s delicate balance can be disrupted by too-aggressive nutritional treatment.

During recovery, problems may arise that require medical treatment. Some people experience tremors, seizures, or other neurological problems caused by abnormal phosphate levels, potassium, and magnesium (electrolytes) during the early stages of refeeding. When malnourishment is severe, hospitalization may be necessary to correct drastic electrolyte imbalances.

The best way to prevent complications is to limit both calories and fluids when restarting food in someone who is severely malnourished. Vitamin B1 (thiamine) supplements are given at the beginning of refeeding and continued twice daily for 7-10 days. Problems can usually be avoided by closely monitoring food intake to prevent a rapid increase in daily calories.

Mental health treatment

A mental health clinician typically coordinates care in an eating disorder treatment setting. People with anorexia nervosa often suffer from perfectionism, making them feel that they can never be thin enough. They tend to restrict eating as a way to control high levels of anxiety. Psychological treatment to address flawed thinking and poor self-image often involves several different therapies:

• Individual, group, and family psychotherapy. The multifaceted approach focuses on thinking and behaviors. A psychotherapist works one-on-one to support the individual. Family therapy helps parents and adolescents work through relationship problems or interpersonal issues.
• Cognitive-behavioral therapy (CBT) is the leading evidence-based treatment for adults with eating disorders. It can also be adapted for younger people with anorexia nervosa. The therapy addresses cognitive factors like negative body image, core beliefs about self-worth, and perfectionism. CBT also helps with behavioral factors like dietary restriction, self-harm, and body avoidance.
• Dialectical behavioral therapy (DBT) combines Eastern wisdom with techniques for healthy emotional regulation. The focus is on acceptance (rather than change) and coping with difficult emotions. The DBT approach helps people cope with feelings that tend to trigger unhealthy eating patterns. DBT teaches skills ranging from mindfulness to distress tolerance, emotion regulation, and interpersonal effectiveness.
• Motivation to Change therapy is a therapeutic intervention that works best when someone is ready for behavioral change. Treatment includes support, education, and efforts to increase motivation. The goal is to move someone from denial to acceptance about anorexia nervosa.

Pharmacotherapy. Although not a first-line treatment, medications can help people whose anorexia is related to obsessive-compulsive disorder or other treatable mental illnesses. Specialized treatment may be needed to address various mental health diagnoses.

How Does Anorexia Nervosa Progress?

While symptoms of anorexia vary widely, people with anorexia nervosa can experience life-threatening damage to vital organs like the brain, heart, and kidneys.

Over time, anorexia nervosa causes a range of worsening medical problems:

• Bone loss and muscle weakness
• Bloating and skimpy bowel movements
• Feeling cold all the time and having a low body temperature
• Itchy, scaly, or blotchy skin
• Fine, downy, dark hair on arms, chest, face, and face
• Deficits in memory and attention
• Trouble sleeping
• Decreased ability to recognize hunger
• Low blood pressure
• Headaches and nausea
• Ulcers
• Slow wound healing
• Damage to the colon and digestive system
• Liver and kidney disease
• Cardiovascular complications and congestive heart failure

As the disorder progresses, anorexia nervosa can cause various cardiovascular complications, ranging from dizziness and fainting to irregular heart rhythm. In very severe cases, imbalances in electrolytes like potassium and magnesium can lead to life-threatening heart failure. Medical complications account for more than half of all deaths in people with anorexia nervosa.

How Do I Prevent Anorexia Nervosa?

If anorexia nervosa is suspected, seek professional help early. In general, people don’t simply “outgrow” the disorder. Sometimes, an intervention with family and friends serves as a “wake-up call” for someone who needs help. Sadly, many people with anorexia nervosa refuse treatment, at least initially. The death rate is ten times higher in people with anorexia nervosa than in the general population.

Anorexia Nervosa Caregiver Tips

The most important thing you can do for a loved one with anorexia nervosa is to be supportive. Try these helpful strategies:

• Get an accurate diagnosis.
• Don’t try to reason with someone who has a distorted body image.
• Look into a treatment center that specializes in eating disorders.
• Recognize that weight gain is the cornerstone of treatment.
• Find therapists who can help people with anorexia nervosa develop new patterns of thinking and self-awareness.
• Create a robust support system. The free recovery group Overeaters Anonymous welcomes people with anorexia nervosa as well as other eating disorders. Find a local group.
• Connect with others for support. Family support groups can be beneficial for parents who are struggling to help an adolescent with anorexia nervosa.

Many people with anorexia also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with anorexia:

• About a third of people with anorexia also suffer from depression.
• As many as two-thirds of people with anorexia have an anxiety disorder such as social anxiety disorder or obsessive-compulsive disorder (OCD) at some point in their lives. OCD is the most common of these disorders among people with anorexia or other eating disorders.
• ADHD is common among people with the binge-purge type of anorexia.
• Many people with anorexia and other eating disorders have problems with alcohol abuse or alcoholism. Comorbidity of the two disorders is especially common among young women.

Anorexia Nervosa Brain Science

Scientists are studying the complex brain changes caused by anorexia nervosa. Neuroimaging shows subtle but measurable differences in the brains of people with anorexia nervosa compared with those who have never suffered from the disorder.

The brains of people with anorexia nervosa show a different reward response, react differently to feedback, and have altered serotonin — a key neurotransmitter — pathways.

Differences are observed between people currently suffering from anorexia nervosa and those who have recovered from the disorder. It is not understood whether neurobiological differences occur before someone has anorexia nervosa and are physical predictors of the illness — or if these neurobiological differences are “scars” from prolonged starvation.

Individuals with anorexia nervosa have difficulty experiencing pleasure. Compared to people who don’t have anorexia nervosa, the brains of people with anorexia nervosa — or those who have recovered — don’t respond typically to food. The findings suggest that brain circuitry is altered in regions that control taste pleasantness and reward mechanisms.

MRI studies have shown that both active and recovering individuals with anorexia nervosa show enlargement of a particular area of the brain. Research showed increased gray matter in a brain region called the orbitofrontal cortex, which tells the body when to stop eating. Even when someone recovers from the disorder, changes in the brain remain.

Anorexia Nervosa Research

Title: Effects of Psilocybin in Anorexia Nervosa

Stage: Recruiting

Principal investigator: Roland Griffiths, PhD 

Johns Hopkins University

Baltimore, MD

This open-label pilot study seeks to investigate the safety and efficacy of psilocybin in persons with chronic anorexia nervosa (AN). Psilocybin has previously been demonstrated to decrease depression and anxiety and increase long-term positive behavior change in other populations. The investigators seek to determine whether similar changes can be safely produced in people with AN when psilocybin is administered in a supportive setting with close follow-up. The investigators’ primary hypotheses are that psilocybin is safe to administer to people with AN. It will reduce measures of anxiety and depression and lead to increased quality of life. The investigators will also assess a number of exploratory measures related to eating disorder pathophysiology.

Title: Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa

Stage: Completed

Investigator: Angela S. Guarda, MD 

Johns Hopkins University

Baltimore, MD

Safe, tolerable, effective approaches to weight restoration are needed for adults with anorexia nervosa (AN). We examined weight outcomes and patient satisfaction with an integrated, inpatient-partial hospitalization, a meal-based behavioral program that rapidly weight-restores a majority of patients. Method: Consecutively discharged inpatients (N = 149) treated on weight gain protocol completed an anonymous questionnaire assessing treatment satisfaction at inpatient discharge. Responders (107/149) rated their satisfaction with program components, feeling included in treatment, and the likelihood of returning or recommending the program to others. Clinical and demographic data were abstracted by chart review on all cases. Results: Over 70% of adult patients met BMI≥19 kg/m2 by program discharge. The mean inpatient rate of gain was 1.85 kg/week (SD = 0.89). A majority (83.2%) would recommend the program to others and 71.4% endorsed a willingness to return if needed. The behavioral treatment focus was rated highly by 82.9% of respondents and was the strongest predictor of the likelihood of referring others. Discussion: Results indicate a behaviorally focused, integrated, meal-based specialty program for eating disorders that includes rapid weight gain is acceptable to most participants. Data have implications for quality care, outcome reporting, and cost-effectiveness of inpatient behavioral weight restoration programs for individuals with AN.