Anorexia Nervosa


What is Anorexia Nervosa?

Anorexia Nervosa is an eating disorder that is characterized by dietary restriction, significantly low body weight, intense fear of weight gain, and a distorted body image. The average age of onset for anorexia nervosa is in the early to mid teenage years, though it is not uncommon for anorexia to start at an earlier or later age. It is unusual for the disorder to manifest after the age of 30. Anorexia nervosa effects more females than males with 90-95% of individuals suffering from anorexia being female.

Dietary Restriction

Individuals who suffer from anorexia nervosa will eat far less than what would be expected. This is often tied to a fear of weight gain and the belief they may have that they are overweight. Individuals with anorexia nervosa may avoid certain types of foods (e.g. carbs, protein, or foods high in fat content). Sometimes, people suffering from anorexia nervosa will also be restriction of fluid intake, which can quickly become particularly dangerous due to related heart issues (tachycardia) and dehydration. The result of these behaviors is unhealthy weight loss.

Significantly low body weight

In the 2013 update of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) there was a removal of a clear definition of what level of body weight is needed for a diagnosis for anorexia nervosa. In the previous version of the DSM, the requirement for a diagnosis of anorexia nervosa was that a person must be less than 85% of their ideal body weight (the weight expected given age, height, sex, and developmental level). There are a few ways to identify "ideal body weight" with the most frequently used being Body Mass Index (BMI).

Intense fear of weight gain

The majority of individuals suffering from anorexia nervosa will voice and express an intense fear of weight gain. Others, however, may state that they do not have fear of weight gain, though they may be closed off to efforts to achieve this goal. This intense fear of weight gain in the person suffering from anorexia nervosa, results in their avoidance of foods that may result in weight gain.

Distorted body image

People suffering from anorexia nervosa quite frequently have a distorted sense of their own body and weight. The classic image that is often described is the emaciated woman who is looking in the mirror and sees an overweight reflection. In many ways this is quite true. The individuals suffering from anorexia nervosa may believe that they are at an appropriate weight or even overweight despite being significantly underweight. Along with a distorted body image, individuals suffering from anorexia may also believe that "everyone is making a bigger deal of this than is needed." In this way, there is often a sense of denial about the severity of their struggle.


Medical Problems Associated with Anorexia Nervosa

There are many medical problems that are associated with anorexia nervosa. Even beyond medical issues that may arise, anorexia nervosa has the highest mortality rate rate of any psychiatric disorder with an estimated 1 in 10 individuals who reaches the inpatient care dying of the disorder or related issues at some point in their life. Below I have laid out some of the short term and long term medical concerns that individuals suffering from anorexia may experience.

Heart Problems

When individuals with anorexia nervosa restrict their intake of food for an extended period of time, their heart rate and blood pressure slowly (and sometimes quickly) drop to dangerously low levels. There is a significantly increased risk for heart failure as heart rate and blood pressure drop. Low heart rate is called bradycardia. Problems related to bradycardia can also include fainting due to the brain not receiving enough oxygen. Fainting can occur at any time, including when someone is operating a motor vehicle or in other dangerous situations.

For individuals suffering from anorexia nervosa who engage in purging, hypokalemia (e.g. low potassium) is also a potential significant problem that can lead to heart arrhythmia or heart failure. This can occur even when purge behaviors are not present.

Osteoporosis

Along with the restriction of food intake in anorexia nervosa comes various hormonal problems that effect levels of bone density in females. Low body weight can result in decreases in production of estrogen. This can lead to amenorrhea as well as the loss of bone density associated with low estrogen. It is beyond the scope of this section, but other hormonal changes associated with anorexia nervosa further result in the decrease of bone density and often result in osteopenia or osteoporosis

Dehydration and Kidney Failure

There are various ways that malnutrition from anorexia nervosa may result in kidney problems and possible renal failure. Some of this is associated with the decrease of protein intake as well as changes in the body that then process protein differently. 

Dehydration is common in individuals suffering from anorexia nervosa and can result in many issues including tachycardia (abnormally high heart rate associated with heart problems) as well as kidney problems.

Muscle Loss 

Many individuals suffering from anorexia nervosa aim to decrease their overall weight with the goal of losing "fat." However, long-term malnutrition puts the body in starvation mode and the body will lose significant muscle. Therefore muscle loss and overall fatigue may increase for the individuals suffering from anorexia nervosa.

Others

There are far more medical issues that can arise from anorexia nervosa and are specific to the individual's particular eating disordered behaviors. This list is not meant to be exhaustive, but rather to share that significant medical problems and even death can result from anorexia nervosa. Please seek the help of a qualified medical professional for your individual needs.


Treatment of Anorexia Nervosa

Due to many issues including medical complications that arise, treatment for anorexia nervosa may look different than for many other mental health issues. I will describe levels of care in more detail. Keep in mind that choosing the appropriate level of care often involves listening to loved ones and professionals who know you and your situation well. While many individuals suffering from anorexia nervosa prefer less intensive forms of support, higher levels of care that offer more support are often needed. 

I will briefly describe a few levels of care and then describe several approaches to treating anorexia nervosa that are often used at each level of care.

1. Levels of Care

Inpatient Hospitalization

For many individuals with anorexia nervosa, the disorder becomes so severe that they need immediate medical help. In this way, it is not infrequent for individuals to arrive at a local hospital emergency room in order to get immediate medical care for things like heart issues, dehydration, fainting, etc. For such individuals, a stay at a medical hospital for treatment is often required.

However, following a stay at a medical hospital, there is often need for further stabilization within an inpatient psychiatric hospital for eating disorder treatment. Such programs often include group therapy, dietary counseling, medication management by a psychiatrist, and 24/7 nursing care. Typical length of stay varies depending on a number of factors.

Residential Treatment

This level of care involves 24/7 treatment for anorexia nervosa for an extended period of time (1-3 months) often in a more homelike environment. Treatment would include individual therapy, group therapy, dietary counseling, family therapy, and medication management. Such programs for anorexia nervosa tend to be highly therapy centered and seek to help individuals move toward recovery in supportive, caring settings. The length of such treatment is often a strength as it helps individuals form new habits over time rather than a "quick fix." Not all insurance companies offer "residential benefits," so you may want to look into your insurance benefits or consider out-of-network benefits you may have.

Partial Hospitalization

Also called day treatment programs, this level of care involves 15-30+ hours per week of treatment for anorexia nervosa (depending on state laws and program). Often these programs will run from 8:00am-2:00pm (for example) 3-5 days per week and include 2 supervised meals per day. Individuals within these programs may expect to receive individual therapy, group therapy, family therapy, dietary counseling, and medication management - though therapies are often less frequent than they would receive in residential treatment. 

Intensive Outpatient

Intensive outpatient treatment for anorexia nervosa may include 3-4 evenings (typically) 3 hours per week. Such programs would include 1 supervised meal per evening as well as a meal process group and/or group therapy. Some programs offer individual therapy while others do not. Medication management is sometimes offered as well, but frequently done outside of the particular program.

Outpatient

Outpatient therapy for anorexia nervosa generally involves meeting with a therapist 1x per week, meeting with a dietitian 1-2x per month, meetings with their primary care physician (as needed), and medication management with a psychiatrist (if indicated). 

2. Treatment Modalities for Anorexia Nervosa

It should be noted that, in addition to therapy, it is best practice that individuals suffering from anorexia nervosa regularly see a medical doctor, dietitian, and a psychiatrist (if indicated) as part of their outpatient team. 

Cognitive Behavioral Therapy (CBT)

There is limited evidence that suggests CBT is a helpful treatment modality in helping individuals recover from anorexia nervosa. However, CBT is likely more helpful when the individuals 1) has regained necessary weight in a higher level of care, 2) has insight into the eating disorder, and 3) possesses motivation to change. CBT has typically been found to be more helpful for bulimia nervosa than anorexia nervosa. CBT is often used in all levels of care described above.

Exposure with Response Prevention (ERP)

Some recent studies led by Columbia researcher Joanna Steinglass have found support for the use of ERP for individuals suffering from anorexia nervosa. ERP is a largely behavioral treatment for Obsessive Compulsive Disorder and many elements are used for phobia and other anxiety disorders. The essential components are 1) to systematically expose the individual suffering with anorexia nervosa to their feared foods and 2) encourage them to refrain from engaging in their typical response (dietary restriction). Note: the client is not forced to comply with any request, but is encouraged by supportive professionals. ERP, as described in studies by Steinglass, was present primarily in the inpatient level of care. However, this does not necessarily mean that it could only be successful there.

Maudsley Method (Family Based Treatment - FBT)

There has been quite a bit of research that supports the use of FBT for anorexia nervosa in adolescents. FBT is a form of treatment for anorexia nervosa that seeks to place the parents in an active role in the recovery process of their adolescent. FBT typically takes place in the outpatient level of care, though early in the process of medical stabilization, inpatient care may be required. There are three phases to recovery in FBT. 

Phase 1 | Weight Restoration

Parent(s) take an active and supportive stance with their adolescent during phase 1 of the recovery process from anorexia and are responsible to help their adolescent regain the needed weight. The therapist working with the family helps parents to be supportive and non-judgemental, but also consistent in the expectation that their child needs to eat. 

Phase 2 | Return Control Over Eating to Adolescent

As the adolescent progresses and makes more and more positive decisions surrounding food and eating, the parents will slowly hand control over food choices and eating to their adolescent. This is typically a progressive return of control as responsibility and positive decision making is present.

Phase 3 | Establish Healthy Adolescent Identity

This phase typically starts when the adolescent has displayed the ability to maintain weight at or above 95% of their ideal body weight (IBW) for a specified length of time. Focus of therapy and work then transitions toward helping the adolescent gain a sense of identity in their life outside of anorexia nervosa, seeking a normalized transition to positive, healthy adolescent activity.