Signs and Symptoms of Anorexia Nervosa

Anorexia nervosa is a psychiatric illness characterized by an inability to maintain an adequate, healthy body weight.

The disorder, which is observed in around 1% of the population, affects primarily young females, although more and more men are beginning to develop anorexia nervosa¹Keski-Rahkonen A, Hoek HW, Susser ES, et al. Epidemiology and course of anorexia nervosa in the community. American Journal of Psychiatry. 2007;164(8):1259-1265..

Anorexia nervosa is a debilitating condition that profoundly impacts a person’s physical, psychological, social, and spiritual wellbeing.

It has the highest mortality rate of any psychiatric disorder, even including depression, anxiety, and substance abuse disorder²Arcelus J, Mitchell AJ, Wales J, et al. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of general psychiatry. 2011;68(7):724- 731..

• The weighted mortality rate (i.e., the deaths per 1000 persons) of anorexia nervosa is estimated to be 5.1 – which is more than double the weighted mortality rate for other eating disorders such as bulimia nervosa³Arcelus J, Mitchell AJ, Wales J, et al. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of general psychiatry. 2011;68(7):724-731..
• A significant percentage of deaths resulting from the disorder are caused by either suicide or medical complications⁴Fairburn CG, Harrison PJ. Eating disorders. The Lancet. 2003;361:407-416..

Diagnostic Criteria

The diagnostic criteria for anorexia nervosa are outlined in the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-V). In order to receive a diagnosis of anorexia nervosa, the person must display:

1. Chronic energy restriction leading to significantly low body weight (of what it expected for a person’s age, sex, developmental trajectory, and physical health)
2. Either an intense fear of weight gain or of becoming fat, or persistent behaviour that interferes with weight gain.
3. Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

There are two main subtypes of anorexia nervosa that must be distinguished:

1. Binge-purge subtype: where a person chronically restricts their food intake, but also during certain periods of restriction the person has engaged in binge eating or some form of purging behaviour, such as self-induced vomiting, laxative misuse, or diuretic misuse.
2. Restricting subtype: the restricting subtype is the more common anorexia nervosa subtype. This is where a person severely restricts their food intake via methods such as maintaining very low calorie count, restricting the types of food eaten, or eating only one meal a day.

Warning signs and Symptoms

There are a whole host of warning signs and symptoms of anorexia nervosa.

Some of the more common signs and symptoms are:

Overvaluation of weight and shape

Most people with anorexia nervosa define their self-worth in terms of how they look or how much they weigh. This “overvaluation of weight and shape” is considered by some to be the core psychopathology of anorexia nervosa, because most other clinical features of anorexia nervosa (e.g., dietary restriction, obsessive body checking etc.) are caused by this⁵Fairburn CG. Cognitive behavior therapy and eating disorders. New York, NY: Guilford Press 2008.. Therefore, targeting overvaluation in treatment is crucial because it may reduce the other features of the disorder⁶Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behavior Research and Therapy. 2003;41:509-528..

Preoccupation with body weight and shape

Preoccupation with weight and shape, a related by different construct from overvaluation, is common in people with anorexia nervosa. Preoccupation occurs when someone cannot stop thinking about their weight and shape, so much so that it consumes most of the sufferers waking life and interferes with their ability to perform basic tasks. Recent research has shown that preoccupation with weight and shape is the facet of body image most strongly predictive of the co-occurring anxiety and depressive symptoms that are common in anorexia nervosa⁷Linardon J, Phillipou A, Castle D, et al. The relative associations of shape and weight over-evaluation, preoccupation, dissatisfaction, and fear of weight gain with measures of psychopathology: An extension study in individuals with anorexia nervosa. Eating Behaviors. 2018;29:54-58..

Intense fear of weight gain

An overwhelming fear of gaining weight — whether it be 100 grams or 5 kilograms — is a key characteristic of anorexia nervosa. This fear will usually cause people to go to extreme lengths to avoid weight gain, including starving oneself, exercising compulsively, and over-consuming laxatives or diuretics. The importance of this feature of body image was highlighted in a recent study showing that, compared with other body image variables (e.g., overvaluation, preoccupation, and body dissatisfaction), fear of weight gain was the only variable that significantly predicted extreme dietary restriction and compulsive exercise patterns in patients with anorexia nervosa⁸Linardon J, Phillipou A, Castle D, et al. The relative associations of shape and weight over-evaluation, preoccupation, dissatisfaction, and fear of weight gain with measures of psychopathology: An extension study in individuals with anorexia nervosa. Eating Behaviors. 2018;29:54-58..

Dietary restriction

The key reason why people with anorexia nervosa are at a very low body weight is because of a persistent and chronic energy restriction⁹Garner DM, Bemis KM. Cognitive therapy for anorexia nervosa. In Garner DM, Garfinkel PE, (Eds). Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: Guilford Press 1985.. People with the disorder can eat as little as a few hundred calories per day. The lack of essential nutrients starves the brain and body, causing various psychological (e.g., obsession with food, loss of interest in sex etc.) and medical (e.g., osteoporosis, anaemia etc.) complications¹⁰Fairburn CG, Harrison PJ. Eating disorders. The Lancet. 2003;361:407-416..

Perfectionistic and rigid thinking

People with anorexia nervosa set unrealistically high standards of themselves in multiple domains of life, including weight, shape and eating¹¹Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy. 1999;37(1):1-13.. They often do this to manage their low self-esteem, and mistakenly believe that if they can meet these high standards then they will have a sense of control and be successful. This way of being usually forces people to take a “black and white” view of the world, where anything below perfection is deemed a failure¹²Egan SJ, Piek JP, Dyck MJ, et al. The role of dichotomous thinking and rigidity in perfectionism. Behav Res Ther. 2007;45:1813-1822.. Perfectionistic and rigid thinking styles are believed to be crucial factors that are responsible for the onset and maintenance of anorexia nervosa¹³Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy. 1999;37(1):1-13..

Social withdrawal

Social withdrawal/isolation is a hallmark of anorexia nervosa. People with the disorder avoid many forms of social contact that usually involve exposure to food or eating (e.g., going to a party or to a family event), or shape and weight (e.g., going to the beach). This social isolation validates the person’s sense of worthlessness and hopelessness, leaving the person to value the things that they perceive they can control – namely their eating, weight, and shape¹⁴Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy. 1999;37(1):1-13..

Repetitive body checking

Body checking can take a variety of forms, such as weighing yourself, staring in front of the mirror, or comparing your own figure to others. The extreme concerns around weight and shape that are so pervasive in anorexia nervosa cause people to obsessively and repeatedly check their body. For example, it is not uncommon for sufferers to weigh themselves multiple times a day or to stare at themselves in front of the mirror for long periods. Research has shown that repetitive body checking in anorexia nervosa not only leads to depression, anxiety, and body dissatisfaction, but it also reinforces the starvation symptoms commonly noted in these people¹⁵Lavender JM, Wonderlich SA, Crosby RD, et al. A naturalistic examination of body checking and dietary restriction in women with anorexia nervosa. Behaviour Research and Therapy. 2013;51:507-511..

Obsessions with food and eating

People with anorexia nervosa usually spend a lot of time thinking about and obsessing over food. They meticulously plan when, what, and how much they are “allowed” to eat. They often engage in ritualistic behaviours to satisfy their obsessions, such as by going to the supermarket to merely browse, preparing meals for family members without eating them, and studying the nutrition content in food. These obsessions fuel, amplify, and exacerbate the perfectionistic and rigid thinking styles seen in this population¹⁶Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy. 1999;37(1):1-13..

Conclusion

There are many signs and symptoms that underpin anorexia nervosa, all of which play an important role in contributing to the psychological, physical, and social impairment seen in these people with the disorder.

Available treatments for anorexia nervosa place considerable attention on addressing these signs and symptoms, particularly cognitive-behavioural therapy, family-based therapy, and interpersonal psychotherapy¹⁷Linardon J, Fairburn CG, Fitzsimmons-Craft EE, et al. The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review. Clinical Psychology Review. 2017;58:125-140..

While anorexia nervosa is a debilitating disorder that greater impacts those affected, recovery is certainly possible through these evidence-based treatments.