Anorexia nervosa

Anorexia nervosa is an eating disorder and a serious, potentially life-threatening, mental health condition.

People who have anorexia are very anxious about their weight and body shape. They try to keep their weight as low as possible by strictly controlling and limiting what they eat. Many people with anorexia will also exercise excessively. They may also use other methods to try to control their weight, including using laxatives, vomiting after eating, and taking stimulant drugs.

Anorexia causes people who have it to be afraid of being ‘fat’. This fear is what causes the other symptoms, leading to weight loss and potential health risks.

Read more about anorexia symptoms

Even when a person with anorexia becomes extremely underweight, they can still feel compelled to lose more weight, and see themselves as being ‘fat’.

Anorexia causes people who have it to focus heavily on food, even when they won’t eat it. For example, they might enjoy cooking for others, but avoid eating any of the meal themselves.

Some people with anorexia binge eat, meaning they eat a lot of food (or what feels to them like a lot of food) in a short space of time. They then try to avoid digesting the food and gaining weight from it by ‘purging’ – either making themselves vomit or using laxatives (medication that causes you to poo).

The symptoms of anorexia usually begin gradually – someone might start a diet to help them lose a little bit of weight, but find that it spirals out of control.

How common is anorexia?

Despite being an uncommon condition, anorexia is the leading cause of mental health-related deaths.

Anorexia can affect anyone – it’s more common in girls and women, with 1 in 100 women affected over the course of their lifetime. For men and boys, anorexia affects approximately 1 in 350 men over the course of their lifetime, and experts advise that it’s becoming more common.

Symptoms of anorexia usually first develop during the teenage years, on average at the age of 15, but it can develop at any time, including in childhood.

The cause of anorexia is unknown, but most experts believe the condition results from a combination of biological, psychological and environmental factors.

Read more about the causes of anorexia

The long-term malnutrition associated with anorexia can cause a range of serious complications, such as:

• osteoporosis (weakening of the bones)
• kidney disease
• heart failure
• infertility

Read more about the complications of anorexia

Treating anorexia

It can be difficult for people with anorexia to recognise that they have a mental health condition. Because it’s hard for them to get out of the habits they’ve developed as a result of anorexia, recovery can take some time.

Most people with anorexia respond to treatment, and the earlier it begins, the better the chances of a complete recovery. Treatment for anorexia usually involves talking therapies, such as cognitive behavioural therapy (CBT), which aim to change the person’s thoughts, feelings, and behaviour around food. Nutritional support is also offered to help them gain weight safely.

Read more about treating anorexia

There are 3 main symptoms of anorexia:

• fear of ‘being fat’ or gaining weight
• problems with self-esteem and body image when it comes to food and weight
• restricting food intake and keeping your body weight low, to the point it’s unhealthy

Restricting food intake means your body isn’t getting enough energy or nutrition, which leads to other physical symptoms.

Fear of gaining weight or ‘being fat’

Having anorexia nervosa doesn’t mean you don’t like food, or don’t feel hungry – it means the mental health condition is preventing you from eating in a healthy way. People with anorexia are unable to think about food in the same way as people who don’t have the condition. Instead of thinking about food as something you need to survive, someone with anorexia might be continually focused on how they can eat less, and think of different types of food as ‘bad’ or ‘good’.

Anorexia can make it feel like you have to conceal your eating habits, for example by:

• hiding how much you’ve eaten, or not eaten
• avoiding eating around other people
• coming up with reasons for not eating, like feeling ill, special dietary requirements, or telling people you ate before you saw them

In addition, you may find yourself thinking about food all the time.

Self-esteem and body image

How you feel about food and your body is very personal, so symptoms and thoughts related to anorexia aren’t likely to be the same for everyone. However, there are certain ways of thinking that are common in people who have anorexia.

Anorexia can cause you to think, for example:

• that you’re overweight or ‘fat’
• that you’re unattractive or ugly
• that other people see you in a negative way – maybe that they’ll find you ugly or judge you for the way you look

Also, people with anorexia often believe that they are worth more, and people will like them more, if they are thinner. They might wear baggy clothing to hide their bodies, and withdraw from social situations and hobbies.

Many people will also do something called ‘body-checking’, which involves persistently and repeatedly:

• weighing themselves
• measuring themselves, such as their waist size
• checking their body in the mirror

Men with anorexia, in particular, can spend a lot of time focusing on their muscle mass, and trying to attain a specific body shape.

Anorexia symptoms can make it difficult to concentrate, and cause you to have problems performing at school or work. People with anorexia often seem to lose interest in activities they used to enjoy, but they can seem very busy because of the time they spend thinking about food and weight.

Eating and food

People with anorexia nervosa strictly control what they eat. For example, by:

• strict dieting
• counting the calories in food
• avoiding food they think is fattening
• eating only low-calorie food
• missing meals (fasting)
• hiding food instead of eating it
• cutting food into tiny pieces – to make it less obvious that they’ve eaten very little, and to make the food easier to swallow
• taking appetite suppressants (which make you less hungry), or pills that claim to help your body digest food faster, or remove fat from food

They may also drink a lot of coffee, energy drinks, tea, and other fluids with caffeine to provide a short-term burst of energy without many calories.

Some people with anorexia also use drugs known to cause weight loss, such as cocaine or amphetamines.

Exercise

The compulsion to burn calories often draws people with anorexia to ‘high-impact’ activities, such as running, dancing or aerobics. Some people with anorexia will use any available opportunity to burn calories, such as pacing or preferring to stand rather than sit.

Purging

People with anorexia may think they can avoid absorbing calories, and try to prevent it in various ways. This can involve making themselves vomit.

Signs that someone is purging by vomiting can include:

• leaving the room immediately after eating
• dental problems, such as tooth decay or bad breath, caused by the acid in vomit damaging their teeth and mouth
• hard skin on their knuckles, caused by putting their fingers down their throat

Someone with anorexia might also try to make food pass through their body as quickly as possible. For example, by either taking:

• laxatives (medication that helps to empty the bowels)
• diuretics (medication that helps remove fluid from the body)

In reality, vomiting, laxatives and diuretics all have little effect on the calories absorbed from food.

Other signs of anorexia

Eating too little for a long time can result in physical symptoms, such as:

• fine downy hair (lanugo) growing on the body
• more hair on the face
• pubic hair becoming sparse and thin
• slow or irregular heartbeat

People with anorexia may also:

• have pain in their abdomen (tummy)
• feel bloated or constipated
• have swelling in their feet, hands or face
• feel very tired
• have low blood pressure (hypotension)
• feel cold or have a low body temperature
• feel light-headed or dizzy

In children with anorexia, puberty and the associated growth spurt may be delayed. They may gain less weight than expected for someone going through puberty, and they might be shorter than other people of the same age.

Women and older girls with anorexia may stop having their periods. Anorexia can also lead to infertility, for both men and women.

The exact causes of anorexia nervosa are unclear, but most specialists believe it's likely to be the result of a combination of factors.

Psychological factors

Many people who develop anorexia share certain patterns of thinking and behaving that may make them more likely to develop the condition. These include:

• a tendency towards depression and anxiety
• finding it difficult to handle stress
• frequently worrying and feeling scared or doubtful about the future
• perfectionism – setting strict, demanding goals or standards
• finding it hard to express feelings
• experiencing unwanted thoughts, images or urges that make them feel they have to behave in certain ways

Environmental factors

Environmental factors are parts of the world around a person, and events happening in their life, that can affect their mental wellbeing in a variety of ways.

Puberty can be an important factor contributing to anorexia. This is likely due to the combination of hormonal changes and feelings of stress, anxiety and low self-esteem during puberty.

Western culture and society may also play a part. People of all ages are exposed to a wide range of media messages promoting the idea that only certain body shapes are desirable, and that not having the ‘ideal’ body is something to be ashamed of. Even health advice that’s intended to be helpful can have a focus on the risks of being overweight, which can add to feelings of pressure and low self-esteem.

The media also places significant focus on celebrities’ bodies, pointing out things like cellulite or slight weight gain. This can make people feel insecure about these parts of their own bodies.

Other environmental factors that can contribute towards anorexia include:

• pressure and stress at school, such as exams or bullying – particularly if someone is bullied about body weight or shape
• occupations or hobbies where being thin is seen as the ideal, such as dancing or athletics
• having a family that places high value on being thin and physically active, and praises or rewards weight loss
• a stressful life event, such as losing a job, the breakdown of a relationship, or bereavement
• difficult family relationships
• physical or sexual abuse

Biological and genetic factors

Experts have suggested changes in brain function or hormone levels may also have a role in anorexia, although it's not clear if these lead to anorexia or if they develop later as a result of malnutrition.

These changes may affect the part of the brain that controls appetite, or may lead to feelings of anxiety and guilt when eating. These feelings are then eased when meals are missed, or after excessive exercise.

The risk of someone developing anorexia is also thought to be greater in people with a family history of eating disorders, depression, or substance misuse, which suggests higher chances of developing these conditions could run in the family.

When making a diagnosis, your GP will probably ask questions about your weight and eating habits. For example, they could ask:

• if you’ve lost a lot of weight recently or quite quickly
• how you feel about your weight, and if you’re concerned about it
• if you think you’re overweight, even though other people think you’re thin
• if you make yourself vomit regularly
• if you have periods, whether your periods have stopped and if so, for how long

It’s important to answer these questions honestly. Your GP isn’t trying to judge you or ‘catch you out’. They just need to accurately assess how serious your symptoms are.

Weight and BMI

Your GP may check your weight. If someone has anorexia nervosa, their weight is generally at least 15% below average for their age, sex and height.

Your GP may also calculate your body mass index (BMI). A healthy BMI for adults in Scotland is 20-25. People with anorexia generally have a BMI below 17.5.

Find out how to calculate your BMI

Blood tests and other tests

Your GP may not need to carry out any tests to diagnose anorexia nervosa, but they’ll probably check your pulse and blood pressure.

If you have anorexia, you have a higher risk of developing some heart conditions, such as irregular heartbeat (arrhythmia). Sometimes an ECG (electrocardiogram) may be needed to check how well your heart is working.

Your GP may do blood tests to check the level of:

• fluids in your body
• chemicals or minerals, such as potassium in your blood

Blood tests look for the complications of anorexia, so even if they come back as ‘normal’, it’s still likely you’ll benefit from a referral to a specialist if you’re experiencing anorexia symptoms.

Read more about the complications of anorexia

Referral to a specialist

If your GP thinks you may have anorexia, they’ll refer you to a specialist in eating disorders for a more detailed assessment. Your GP sometimes carries out this assessment.

Read more about treating anorexia

Before your treatment begins, you will probably have an overall assessment of your health. This may be done by your GP or another healthcare professional, such as one that specialises in eating disorders.

The assessment will help your healthcare professional draw up a plan for your treatment and care. For example, they may assess:

• your overall health and any medical needs
• your social situation, such as how much support you have from family and friends
• your mood and any risks that affect you, such as whether you're at risk of harming yourself
• whether there are any physical risks as a result of anorexia that mean urgent treatment is needed

Your care plan

If you are diagnosed with anorexia nervosa, your GP will probably be involved in your ongoing treatment and care. Other healthcare professionals may also be involved in your treatment, such as:

• a specialist counsellor
• a psychiatrist (doctor who specialises in treating mental health conditions)
• a psychologist or psychotherapist
• a nurse
• a dietician (specialist in nutrition)

If a child or teenager has anorexia, a paediatrician (doctor who specialises in children) may also be involved in their treatment.

Where you are treated may depend on how mild or severe your condition is. For example, you may be treated:

• as an outpatient (this is most common)
• as a day patient or in a day unit
• as in inpatient in hospital, if your weight loss or symptoms are severe

In some areas, eating disorders such as anorexia are treated by community mental health teams, which are made up of different health and social care professionals.

In other areas, there are units that specialise in treating eating disorders. Some services that treat eating disorders also specialise in treating young people.

What to expect from anorexia treatment

It’s important to start treatment as early as possible, especially if someone has already lost a lot of weight.

Treatment for anorexia usually includes:

• psychological treatment – talking to a therapist or counsellor
• advice on eating and nutrition to help you gain weight safely

These treatments work better when combined, rather than on their own.

Your physical health will be monitored closely during your treatment. For example:

• your weight will be checked regularly
• you may have regular health checks with your GP or another healthcare professional

In children and young people with anorexia, their growth, development and weight will be monitored closely. Their height will also be checked regularly against the average for their age and sex.

Other health problems caused by anorexia will also be treated. For example, if you vomit regularly, you’ll be encouraged to stop. You’ll be given advice on dental hygiene to help prevent stomach acid damaging the enamel on your teeth. You’ll also be advised to visit a dentist regularly. If you take laxatives or diuretics, you’ll be advised to reduce them gradually so your body can adjust. Stopping them suddenly can cause side effects like nausea and constipation.

Gaining weight safely

Your care team will give you advice on how to increase the amount you eat so you can gain weight safely.

They’ll ask about your current eating habits and how much fluid you drink, as well as habits like smoking and drinking alcohol. This will determine what advice they give you, and help them identify any deficiencies in your diet, such as a lack of vitamins.

Your care team will help you to develop healthy eating habits, such as eating more, eating more healthily, and increasing the nutritional benefits you get from food.

Your body will likely need time to adjust to eating more. You may need to start by eating small amounts of food, and then gradually increasing what you eat.

You may need to take supplements, such as multivitamins or multiminerals, to adjust the chemical balance in your body. Some experts think this should be done before you start gaining weight.

You and your care team will work towards establishing a regular pattern of eating, with three meals a day and regular snacks. Your care team might agree a target weight with you, so you have a minimum healthy weight to aim for.

If your weight loss is severe, treatment in hospital may be needed to help you start to gain weight. Your health will be closely monitored to avoid any side effects, particularly in the first few days.

Types of psychological treatment

Various types of psychological treatment can be used to treat anorexia, such as:

• cognitive analytic therapy (CAT)
• cognitive behavioural therapy (CBT)
• interpersonal therapy (IPT)
• focal psychodynamic therapy (FPT)
• family therapy

These different types of psychological treatments are discussed below.

Cognitive analytic therapy (CAT)

CAT is based on the theory that mental health conditions like anorexia are caused by unhealthy patterns of behaviour and thinking, which a person has developed in their past, usually in their childhood.

Cognitive behavioural therapy (CBT)

CBT starts with the idea that thoughts, feelings, and behaviour are linked and affect one another. If anorexia is causing someone to behave in an unhealthy way, CBT helps them to change the harmful behaviour while working on changing how they think about food, eating, and weight.

Interpersonal therapy (IPT)

IPT is based on the idea that relationships with other people and the outside world in general have a range of effects on your mental health, both positive and negative. IPT explores the way you interact with other people and the relationships you have, with the goal of improving them.

Focal psychodynamic therapy (FPT)

Previous experiences, particularly from childhood, can influence the way you think and feel now in ways you’re not aware of. The aim of FPT is to help you become aware of those effects, so you can understand why you think and feel the way you do about food, eating, and weight.

Family therapy

Anorexia doesn’t just affect one person – it can also have a big impact on their family.

Family therapy involves the person with anorexia and close members of their family discussing how anorexia has affected them, and the positive changes the person and their family can make.

Learn more about talking therapies

The types of therapy available can vary depending on where you live. Although different types of therapy take different approaches, the most important part of any talking therapy is the relationship you build with your therapist.

Medication

Medication alone isn’t usually effective in reducing anorexia symptoms. For some people it can be helpful to prescribe medication in combination with psychological treatment.

Your treatment team might prescribe nutritional or vitamin supplements for you to help your overall health.

If treatment isn’t improving your symptoms, or you start to get worse, your healthcare professional may consider changing your treatment. This may include treatment in hospital if your health is seriously at risk.

Compulsory treatment

Sometimes the physical health issues caused by anorexia mean a person has to be admitted to hospital. If their life is at risk and they refuse treatment, there are some circumstances when they might be admitted under the Mental Health (Care and Treatment) (Scotland) Act 2015. This is sometimes called ‘being sectioned’.

Someone can only receive compulsory treatment if their condition is preventing them from making informed decisions about their care.

Relapsing

It’s quite common for anorexia to return after treatment – this is often referred to as relapse. It can happen, for example:

• if someone’s weight starts to fall again
• after having a baby, when a woman tries to lose the weight she gained during pregnancy
• during stressful times in a person’s life

Sometimes, anorexia can lead to another eating disorder called bulimia nervosa, where the person binge eats, then immediately makes themselves sick or uses laxatives to rid their body of the food.

If someone has anorexia for a long time, it can lead to severe complications and health problems that can sometimes be permanent.

People with anorexia have an increased risk of:

• poor circulation and cardiovascular problems
• heart conditions, such as coronary heart disease and irregular heartbeat (arrhythmia)
• health problems caused by malnutrition – a lack of vitamins and minerals

Anorexia can cause an imbalance of minerals in the blood, such as potassium, calcium and sodium. These minerals play an important part in keeping you healthy. When there’s an imbalance, it can cause symptoms like:

• tiredness
• weakness
• dehydration
• fits
• irregular heartbeat (arrhythmia)
• muscle spasms
• confusion

Health conditions

Other conditions that can be caused by anorexia and malnutrition can include:

• low blood pressure (hypotension)
• anaemia
• dental problems, such as tooth decay caused by regular vomiting (stomach acid affects the enamel on the teeth)
• low blood sugar levels (hypoglycaemia)
• acute kidney (renal) failure
• liver damage
• heart failure
• osteoporosis (fragile bones) and loss of muscle strength, particularly in women and girls
• loss of sex drive (libido) and impotency in men

Misuse of laxatives can damage the bowels and cause permanent constipation.

Anorexia and other health conditions

If you have anorexia and another health condition, you’ll need to take extra care of your health.

If you have diabetes, you’ll need regular health checks to help avoid problems with your eyes or other serious complications. This is particularly important if you have type 1 diabetes.

If you have a bone condition, such as osteoporosis, your GP will probably advise you to avoid any physical activities that may lead to falls.

Anorexia and pregnancy

Anorexia can lead to irregular menstrual cycles, or cause your periods to stop altogether. This doesn’t mean anorexia makes you infertile – if you have anorexia, even if your periods are irregular or have stopped, you should continue to use birth control if you aren’t planning a pregnancy.

If you have anorexia and are trying to become pregnant, you should discuss your plans with your GP and care team.

If you are pregnant, your midwife will monitor your health closely during your pregnancy and after your baby is born. You may need extra health checks as part of your antenatal and postnatal care.

Anorexia during pregnancy can increase the risk of complications, such as:

• miscarriage
• giving birth early (premature birth)
• having a baby with a low birth weight

Having anorexia during pregnancy can also increase the chances that you’ll need to have a caesarean section (C-section).

You’re also likely to need extra care and support during pregnancy if you have previously had anorexia and recovered from it.

If someone has anorexia, the most important step towards diagnosis and treatment is for them to:

• recognise they need help
• want to get better

However, to take this first step they may need lots of support and encouragement. Because one of the main symptoms of anorexia is a fear of gaining weight, it’s understandable that people who have the condition can be anxious about seeking treatment that might mean eating more.

Helping yourself

If you have eating problems or think you may have anorexia, it’s important to seek help as soon as possible. You could start by:

• talking to someone you trust, such as a friend or member of your family
• going to see your GP – you may find it helpful to bring someone with you for support

Helping someone else

If someone close to you is showing signs of anorexia, you can offer help and support.

You could try talking to them about how they feel, and encourage them to think about getting help. Try not to put pressure on them or be critical of them, as this could make things worse. You could also offer to help by going with the person to see their GP.

If you’d like to get some advice on how to help, a healthcare professional, such as your own GP, can provide information on:

• how to help the person recognise that they have a problem
• the treatments available
• how you can support them during their treatment

You could also get help from a support group for people who have loved ones with eating disorders. Your own GP or Scotland’s Service Directory can help you find services near you.

A leading charity for people with eating disorders is Beat, which has a range of information on the help and support available for people with eating disorders, and their friends and families.