Signs and Symptoms

The primary sign of anorexia nervosa is severe weight loss. People with anorexia may try to lose weight by severely limiting how much food they eat. They may also exercise excessively. Some people may engage in binging and purging, similar to bulimia. They may vomit after eating or take laxatives. At the same time, the person may insist that they are overweight.

Physical Signs

• Excessive weight loss
• Scanty or absent menstrual periods (in women)
• Thinning hair
• Dry skin
• Brittle nails
• Cold or swollen hands and feet
• Bloated or upset stomach
• Downy hair covering the body
• Low blood pressure
• Fatigue
• Abnormal heart rhythms
• Osteoporosis

Psychological and Behavioral Signs

• Distorted self-perception (insisting they are overweight when they are thin)
• Being preoccupied with food
• Refusing to eat
• Inability to remember things
• Refusing to acknowledge the seriousness of the illness
• Obsessive-compulsive behavior
• Depression

What To Watch For

• Skipping meals or making excuses not to eat
• Eating only a few foods
• Refusing to eat in public
• Planning and preparing elaborate meals for others, but not eating
• Constantly weighing themselves
• Ritually cutting food into tiny pieces
• Compulsive exercising

Causes

No one knows exactly what causes 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. Serotonin, a brain chemical that is involved in depression, may play a role.
• A cultural environment that puts a high value on thin or lean bodies.
• 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.
• Family history of anorexia. About one fifth of people with anorexia have a relative with an eating disorder.

Risk Factors

Risk factors may include:

• Age and gender. Anorexia is most common in teens and young adult women.
• Dieting
• Weight gain
• Unintentional weight loss
• Puberty
• Having depression, 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).
• Participation in sports and professions that prize a lean body (such as dance, gymnastics, running, figure skating, horse racing, modeling, wrestling, or acting)
• Difficulty dealing with stress (pessimism, tendency to worry, or refusal to confront difficult or negative issues)
• History of sexual abuse or other traumatic event
• Experiencing a big life change, such as moving or going to a new school

Diagnosis

People with anorexia may think they are in control of their disease and do not need help. But if you or a loved one is experiencing signs of anorexia, it is important to seek help. If you are a parent who suspects your child has anorexia, take your child to see a doctor immediately. The doctor will order several laboratory tests and perform a psychological evaluation. If anorexia is suspected, your doctor may use the SCOFF questionnaire, developed in Great Britain. A "yes" response to at least 2 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?"

Lab tests may include:

• Blood tests to look for signs of anemia, to check electrolytes, and to check liver and kidney function
• Electrocardiogram to look for abnormal heart rhythms
• Bone density test to check for osteoporosis

If your doctor diagnoses you with anorexia, you will likely work with a multidisciplinary team including a doctor, a psychologist or psychiatrist, and a registered dietitian.

Preventive Care

The most effective way to prevent anorexia is to develop healthy eating habits and a strong body image from an early age. DO NOT accept cultural values that place a premium on thin, perfect bodies. Make sure you and your children are educated about the life-threatening nature of anorexia.

For people who have already developed anorexia, the primary goal is to avoid relapse.

• Family and friends should be urged not to focus on the person's condition, or on food or weight. DO NOT discuss anorexia at meal times, for example. Instead, devote meal times to social interaction and relaxation.
• Watch for signs of relapse. Careful and frequent monitoring of weight and other physical signs by your doctor can catch problems early.
• Cognitive behavioral therapy, or other forms of psychotherapy, can help the person develop coping skills and change unhealthy thought processes.
• Family therapy can help with any problems in the home that may contribute to the person's anorexia.

Treatment

The most successful treatment is a combination of psychotherapy, family therapy, and medicine. It is important for the person with anorexia to be actively involved in their treatment. Many times the person with anorexia does not think they need treatment. Even if they know they need treatment, anorexia is a long-term challenge that may last a lifetime. People remain vulnerable to relapse when going through stressful periods of their lives.

A combination of treatments can give the person the medical, psychological, and practical support they need. Cognitive behavioral therapy, along with antidepressants, can be an effective treatment for eating disorders. Complementary and alternative (CAM) therapies may help with nutritional deficiencies.

If the person's life is in danger, hospitalization may be needed, particularly under the following circumstances:

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

Even after some weight gain, many people with anorexia remain quite thin and the risk of relapse is very high. Several social influences may make recovery difficult:

• Friends or family who admire how thin the person is
• 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
• The person's belief that extreme thinness 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 may be helpful.

Lifestyle

Treating anorexia nervosa involves major lifestyle changes:

• Establishing regular eating habits and a healthy diet
• Sticking with your treatment and meal plans
• Developing a support system and participating in a support group for help with stress and emotional issues
• Ignoring the urge to weigh yourself or check your appearance constantly
• Cutting back on exercise if obsessive exercise has been part of the disease (Once the person has gained weight, the doctor may set a controlled exercise program to improve overall health)

Medicines

There are no medicines specifically approved to treat anorexia. Antidepressants are often prescribed to treat depression that may accompany anorexia. Your doctor may also prescribe drugs to help with OCD or anxiety. However, medicines may not work alone and should be used in conjunction with a multidisciplinary approach that includes nutritional interventions and psychotherapy.

Selective serotonin reuptake inhibitors (SSRIs) are antidepressants that are sometimes prescribed for people with anorexia. Fluoxetine (Prozac) has been studied in people with anorexia and depression with mixed results. In some early studies, it appeared to increase weight and improve mood over several months. But in another, it helped relieve symptoms of depression, but did not affect the anorexia itself.

Recent studies indicate that the use of Prozac and other antidepressants may cause children and teenagers to have suicidal thoughts. Children who are taking these drugs must be monitored very carefully for signs of suicidal behavior.

People with anorexia may not be getting the essential nutrients their bodies need. Your doctor may prescribe potassium or iron supplements, or other supplements to make up for any deficiency. They may also prescribe cyproheptadine , an antihistamine that may stimulate appetite. In one study, using high doses of cyproheptadine hydrochloride decreased the number of days it took people with anorexia to gain an appropriate amount of weight.

Nutrition and Dietary Supplements

People with bulimia are more likely to have vitamin and mineral deficiencies, which can affect their health. Vitamin deficiencies can contribute to cognitive difficulties such as poor judgment or memory loss. Getting enough vitamins and minerals in your diet or through supplements can correct the problems.

Always tell your doctor 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 overall health:

• Avoid caffeine, alcohol, and tobacco.
• Drink 6 to 8 glasses of filtered water daily.
• Use quality protein sources, such as meat and eggs, whey, and vegetable protein shakes, as part of a balanced program aimed at gaining muscle mass and preventing wasting.
• Avoid refined sugars, such as candy and soft drinks.

Your doctor may suggest addressing nutritional deficiencies with the following supplements:

• A daily multivitamin , containing the antioxidant vitamins A, C, E, the B-vitamins and trace minerals, such as magnesium, calcium, zinc, phosphorus, copper, and selenium.
• Omega-3 fatty acids , such as fish oil, 1 to 2 capsules or 1 tablespoonful oil 2 to 3 times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources; eat 2 servings of fish per week. Fish oil supplementation can potentially increase the risk of bleeding in people with clotting disorders and those taking blood-thinning medicines, such as warfarin (Coumadin) or aspirin.
• Coenzyme Q10 , 100 to 200 mg at bedtime, for antioxidant, immune, and muscular support. Coenzyme Q10 can potentially interfere with Coumadin (warfarin) and other blood-thinning medicines.
• 5-hydroxytryptophan (5-HTP) , 50 mg, 2 to 3 times daily, for mood stabilization. Talk with your doctor if you are on prescription medicines before taking 5-HTP. DO NOT take 5-HTP if you are taking antidepressants.
• Creatine , 5 to 7 grams daily, when needed for muscle weakness and wasting. There is some concern that creatine may be harmful to the liver and kidneys. Until more research is conducted, people who have kidney disease should avoid supplemental creatine. People taking creatine supplements should drink extra water.
• Probiotic supplement (containing Lactobacillus acidophilus among other strains), 5 to 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Refrigerate probiotic supplements for best results.

Herbs

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

• Ashwagandha ( Withania somniferum ) standardized extract, 450 mg, 1 to 2 times daily, for general health benefits and stress. Ashwagandha might cause sleepiness or drowsiness. Be cautious when combining with sedative medicines. People who have a history of gastrointestinal ulcers should not take ashwagandha, as it may irritate the gastrointestinal tract.
• Fenugreek ( Trigonella foenum-graecum) , 250 to 500 mg, 2 to 3 times daily, to stimulate appetite. Fenugreek may not be safe for children. Fenugreek may lower blood sugar, so it is not appropriate in uncontrolled anorexia. It may also interact with diabetes medicines. Fenugreek may interact with medicines that slow blood-clotting (anticoagulant/antiplatelet drugs).
• Milk thistle ( Silybum marianum ) seed standardized extract, 80 to 160 mg, 2 to 3 times daily, for liver health. People with allergies to ragweed family of plants may have sensitivities to Milk thistle. Since Milk thistle works on the liver, there is potential it may affect medicines that are metabolized through the liver. Speak with your physician.
• Catnip ( Nepeta spp.), as a tea 2 to 3 times per day, to calm the nerves and soothe the digestive system. Women with heavy menstrual bleeding should avoid catnip. Catnip can interact with Lithium and certain sedative medicines.

Homeopathy

No scientific literature supports the use of homeopathy for anorexia. However, an experienced homeopath will consider your individual case and may recommend treatments to address both your underlying condition and any current symptoms.

Physical Medicine

There is much anecdotal evidence supporting the use of acupuncture in treating the anxiety and irritability that often coincide with anorexia. Many inpatient eating disorder treatment facilities offer acupuncture as part of their treatment protocol.

Mind-Body Medicine

Cognitive Behavioral Therapy

Cognitive behavioral therapy is one of the most effective therapies for anorexia. In cognitive behavioral therapy, the person learns to replace negative, unrealistic thoughts and beliefs with positive, realistic ones. The person also learns to acknowledge their fears and develop new, healthier ways of solving problems.

Family Therapy

In addition to individual therapy for someone who has anorexia, doctors may recommend family therapy involving parents and siblings. Parents and other family members often have intense feelings of guilt and anxiety to address. Family therapy is aimed, in part, at helping the parents or partner (in the case of an adult) understand the seriousness of this illness and the ways in which family patterns may contribute to it.

Hypnosis

Hypnosis may be helpful as part of an integrated treatment program for anorexia nervosa. Hypnosis may help the person strengthen both self confidence and the ability to cope. That may result in healthier eating, improved body image, and greater self esteem.

Biofeedback

Studies suggest that biofeedback may help reduce stress in people with anorexia.

Body Awareness

Studies suggest aerobic exercise, massage, body awareness therapy and yoga might reduce eating pathology in people with anorexia and bulimia nervosa. These forms of activity may also improve quality of life among people who have an eating disorder.

Other Considerations

Pregnancy

Anorexia poses several potential problems for women who are pregnant or wish 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 triggered by 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
• 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 people with anorexia is variable, with recovery often taking between 4 to 7 years. There is also a high chance of relapse even after recovery. Long-term studies show that 50 to 70% of people recover from anorexia nervosa. However, 25 never fully recover. Up to 20% die from complications of the disease. More people die from anorexia than from any other psychiatric disorder. Many, even after they are considered "cured," continue to show traits of anorexia, such as remaining very thin and striving for perfection. Anorexia is associated with high lifetime mortality from both natural and unnatural causes.

Supporting Research

Barabasz M. Efficacy of hypnotherapy in the treatment of eating disorders. Int J Clin Exp Hypn. 2007 Jul;55(3):318-335. Review.

Birmingham CL, Sidhu FK. Complementary and alternative medical treatments for anorexia nervosa: case report and review of the literature. Eat Weight Disord . 2007 Sep;12(3):e51-e53. Review.

Clarke TK, Weiss AR, Berrettini WH. The genetics of anorexia nervosa. Clin Pharmacol Ther. 2012; 91(2):181-8.

Cook-Darzens S, Doyen C, Mouren MC. Family therapy in the treatment of adolescent anorexia nervosa: current research evidence and its therapeutic implications. Eat Weight Disord. 2008;13(4):157-170.

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):151-155.

Espindola CR, Blay SL. Anorexia nervosa treatment from the patient perspective: a metasynthesis of qualitative studies. Ann Clin Psychiatry. 2009;21(1):38-48.

Ferri: Ferri's Clinical Advisor, 2015, 1st ed. Anorexia Nervosa. St. Louis, MO: Elsevier Mosby. 2014.

Field T. Massage therapy effects. Am Psychol . 1998;53:1270-1281.

Franko DL, Keshaviah A, Eddy KT, et al. A longitudinal investigation of mortality in anorexia nervosa and bulimia nervosa. Am J Psychiatry. 2013; 170(8):917-25.

Goldman. Goldman's Cecil Medicine, 24th ed. Philadelphia, PA: Elsevier Saunders. 2011.

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.

Keski-Rahkonen A, Raevuori A, Bulik CM, Hoek HW, Rissanen A, Kaprio J. Factors associated with recovery from anorexia nervosa: a population-based study. Int J Eat Disord. 2014; 47(2):117-23.

Kishi T, Kafantaris V, Sunday S, Sheridan EM, Correll CU. Are antipsychotics effective for the treatment of anorexia nervosa? Results from a systemic review and meta-analysis. J Clin Psychiatry. 2012; 73(6):e757-e766.

Kleifield EI, Wagner S, Halmi KA. Cognitive-behavioral treatment of anorexia nervosa. Psychiatric Clin N Am . 1996;19:715-737.

LaValle JB, Krinsky DL, Hawkins EB, et al. Natural Therapeutics Pocket Guide . Hudson, OH: LexiComp; 2000: 387-388.

Loeb KL, Walsh BT, Lock J, le Grange D, Jones J, Marcus S, Weaver J, Dobrow I. Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: evidence of successful dissemination. J Am Acad Child Adolesc Psychiatry . 2007 Jul;46(7):792-800.

Lozano GA. Obesity with sexually selected anorexia nervosa. Med Hypotheses. 2008;71(6):933-940.

McNulty. Prevalence and contributing factors of eating disorder behaviors in active duty Navy men. Mil Med. 1997;162(11):753-758.

Moyano D, Sierra C, Brandi N, et al. Antioxidant status in anorexia nervosa. Int J Eating Disord. 1999;25:99-103.

Papadopoulos FC, Ekbom A, Brandt L, Ekselius L. Excess mortality, causes of death and prognostic factors in anorexia nervosa. Br J Psychiatry. 2009;194(1):10-17.

Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Ped Int . 2000;42:76-81.

Rakel: Textbook of Family Medicine, 8th ed. Philadelphia, PA: Elsevier Saunders. 2011.

Rock CL, Vasantharajan S. Vitamin status of eating disorder patients: Relationship to clinical indices and effect of treatment. Int J Eating Disord. 1995;18:257-262.

Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin . 2001;17(1):239-247.

Shay NF, Manigan HF. Neurobiology of zinc-influenced eating behavior. J Nutr. 2000;130:1493S-1499S.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr . 2002;21(6):495-505.

Vancampfort D, Vanderlinden J, De Hert M, et al. A systematic review of physical therapy interventions for patients with anorexia and bulemia nervosa. Disabil Rehabil . 2014; 36(8):628-34.

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs . 2000;9(9):2103-2119.

Wheatland R. Alternative treatment considerations in anorexia nervosa. Med Hypotheses . 2002;59(6):710-715.

Williams PM, Goodie J, Motsinger CD. Treating eating disorders in primary care. Am Fam Physician. 2008 Jan 15;77(2):187-195.

Wiseman CV, Harris WA, Halmi KA. Eating disorders. Medical Clin N Am . 1998;82:145-159.

Wolfe BE, Metzger ED, Jimerson DC. Research update on serotonin function in bulimia nervosa and anorexia nervosa. Psychopharmacol Bull . 1997;33:345-354.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J . 2005;46(5):585-596.

Young D. The use of hypnotherapy in the treatment of eating disorders. Contemporary Hypnosis. 1995;12:148-153.