What is Anorexia Nervosa?

Anorexia Nervosa is one particular type of Eating Disorder which negatively affects the person’s relationship with food and body image. It causes the young person to become preoccupied with weight and body shape to the point that weight loss becomes a central feature of life. Thoughts about body shape and about food become distorted by illness and consequently the person has difficulty making any realistic appraisals about food intake or the individual’s own body shape. Behaviour becomes almost solely directed towards the goal of weight loss with previous interests becoming secondary and relationships with friends and family frequently becoming strained as others struggle to comprehend the behaviour.

Distinguishing ‘normal dieting’ from Eating Disorder Symptoms

  • Denial of being “on a diet” despite obvious restriction and weight loss; Denial of hunger or craving;
  • Claims of needing less food than others;
  • Change in food ‘rules’, e.g. vegetarianism, not eating after 6pm; Attempts to hide weight loss, e.g. wearing baggy clothes; Increased interest in food/cooking for others;
  • Unusual eating behaviours: eating very slowly, chopping food up into tiny amounts, segregating foods;
  • Eating alone;
  • Bathroom trips after eating; Ritualised behaviours;
  • Social isolation, low mood; Increased exercise.
  • Noticeable weight loss;
  • Avoidance of eating with others;
  • Meals left unfinished or thrown away;
  • When eating, moving food around the plate repetitively or cutting food into very small pieces;
  • Using bathroom immediately after eating;
  • Excessive exercise, fidgeting, running;
  • Frequent excuses to explain not eating;
  • Minimisation of weight loss.
  • Low mood; Low energy; Decreased concentration;
  • Decreased ability to perform to potential in work environment;
  • Loss of confidence;
  • Loss of enjoyment of activities;
  • Increasing social isolation and avoidance of friends.
  1. Cardiovascular: Low blood pressure and heart rate. Changes and abnormalities in heart rhythm. The person may complain of feeling weak, dizzy or faint. Gastrointestinal: Slow stomach emptying, bloating, decreased motility in the gastrointestinal system. These may all lead to a feeling of fullness even after eating only a very small amount. There may also be high cholesterol, and abnormal liver function tests.
  2. Renal: Dehydration, kidney stones, abnormal kidney function tests, passing urine more frequently and ankle swelling.
  3. Haematological: Anaemia. Iron deficiency.
  4. Endocrine: Abnormal thyroid functioning, growth failure, osteopenia, swollen salivary glands and amenorrhoea.
  5. Reproductive: Menstrual cycle disturbance and potential infertility.
  6. Central Nervous System: thinning of the brain, seizures.
  7. Other: Dry scaly skin, Muscle wasting and “lanugo” hair (fine downy type hair) on the face; Increased risk of osteoporosis; Cold extremities; Weakness and fainting.

Anorexia is a potentially life-threatening condition, particularly if it is left for a long time without being treated. There is a high mortality rate (approximately 5% per decade) both from medical complications and from suicide. Progress in treatment is frequently slow. Approximately 50% recover and one third have chronic symptoms. The earlier treatment is initiated the better.

Approximately one in a hundred people have Anorexia Nervosa. Anorexia nervosa can affect both males and females of all ages. It is most common amongst girls and young women. Around 10% of people with anorexia are male. Many factors can contribute to making someone more vulnerable to anorexia than another and these factors vary from person to person. Anorexia is not primarily about food and weight issues or about ‘slimming’. As with all eating disorders, the psychological issues and emotional distress underlying the physical symptoms must be addressed for long-term recovery to be possible.

There is no single cause of Anorexia Nervosa and it is described as ‘multifactorial’ in origin. The person may be predisposed to developing the illness for a number of reasons including individual factors, family factors and cultural factors. Anorexia Nervosa may develop following a ‘normal’ diet which goes out of control. The ‘trigger’ for Anorexia could be one or more of a multiplicity of factors. For example, in a person who is vulnerable to developing an Eating Disorder, the trigger could be a stressful life-event such as work or bereavement or critical comment by a peer about shape and size. The person may experience the control of food intake as helping to minimise the effects of other stresses.

  • Genetic Factors
    Researchers have proven that Anorexia Nervosa has a genetic component. This has been explored by research with identical twins. It has been shown that when one identical twin has Anorexia Nervosa, the other twin is more likely to develop the illness when compared to non-identical twins. This provides proof of the genetic contribution to the development of Anorexia Nervosa, as the greater the genetic similarity the higher the likelihood of developing the illness. There is also an increased rate of Eating Disorder in siblings. Furthermore, parents who themselves have eating concerns may pass this on to children.
  • Psychological Factors
    There are a number of psychological theories that have been proposed to explain the development of Anorexia Nervosa. People who develop Anorexia Nervosa are commonly noted to have perfectionistic traits. A person with Anorexia Nervosa typically bases self-worth on thinness. In the case of children and young adults some theorists have suggested that Anorexia Nervosa develops as a result of the young person’s fear of growing up. This theory proposes that the young person with Anorexia Nervosa prevents sexual development by not eating and consequently maintaining the body in a prepubertal state.
  • Cultural Factors
    As mentioned above, there has been much recent debate in the popular media about the role of the ‘fitness culture’ on social media in precipitating Anorexia Nervosa. St John of God Hospital in Dublin’s Stillorgan has warned of a real increase in young women presenting at the clinic with a real aversion to certain food groups, encouraged by the “healthy, Instagram lifestyle”. In 2016 a review of all studies on social media and its impact on body dissatisfaction and eating disorder behaviours revealed that higher rates of social media use is associated with body image dissatisfaction and disordered eating behaviour. Focus groups conducted with young people by Bodywhys identified social media as the main pressure on body image and self-esteem.

Because of the nature of the disorder, a person with anorexia may have difficulty admitting to the seriousness of the risks to their physical and their mental health. The prospect of recovery can be very frightening and resistance to treatment is normal. This may have the effect of delaying appropriate treatment and can cause severe distress for carers and family members. Carers should seek information and support for themselves to increase their understanding of the disorder and their ability to help. Attending a support group for family and friends can be helpful.

The overall aim of treatment is to:

  1. Restore a healthy Body Mass Index.
  2. Change the faulty, maladaptive thinking that is integral to Anorexia Nervosa, for example, morbid fear of fatness, belief that one is fat despite evidence to the contrary.
  3. Address other non-food/ weight issues such as perfectionism and interpersonal relationship problems.

Some people may require hospitalisation. The time needed for recovery from anorexia nervosa varies according to each individual.The general clinical approach is to encourage a stepwise return to a balanced diet using ‘behavioural’ principles. The person’s target Body Mass Index is calculated as is target daily calorific intake (which increases as treatment progresses). A ‘contract’ is agreed with the person that details rewards which are contingent on successfully reaching an agreed target and consequences for the person if calorific intake is not maintained.

Psychoeducation: is a fundamental aspect of treatment. This involves increasing the person’s awareness of the need for regular meals and regular exercise. Providing their family/partner/carer with information on Eating Disorders and the physical, behavioural and psychological effects of starvation is essential.

Cognitive Behavioural Therapy: is also used in the treatment of Anorexia Nervosa. This form of therapy focuses on helping the person challenge beliefs about thinness, body-shape, food and exercise. The person is helped to make links between thinking about food and weight and behaviour, such as restricting food intake. The person is encouraged to see the link between thoughts such as ‘I am fat’ and feeling states such as sadness and to develop alternative strategies to deal with these thoughts.

The HSE has a National Clinical programme for Eating Disorders (NCP-ED) in collaboration with the College of Psychiatrists of Ireland and BodyWhys, the national support group for people with eating disorders.

For information on the HSE’s Eating Disorder Self Help app and a link to download, click here.

For more information on the clinical programme, click here.