Symptoms

Some people with anorexia lose weight mainly through severely restricting the amount of food they eat. They may also try to lose weight by exercising excessively. Others with anorexia binge and purge, similar to bulimia. They control calorie intake by vomiting after eating or by misusing laxatives, diuretics or enemas.

No matter how weight loss is achieved, anorexia has a number of physical, emotional and behavioral signs and symptoms.

Physical anorexia symptoms Physical signs and symptoms of anorexia include:

• Extreme weight loss
• Thin appearance
• Abnormal blood counts
• Fatigue
• Insomnia
• Dizziness or fainting
• A bluish discoloration of the fingers
• Hair that thins, breaks or falls out
• Soft, downy hair covering the body
• Absence of menstruation
• Constipation
• Dry skin
• Intolerance of cold
• Irregular heart rhythms
• Low blood pressure
• Dehydration
• Osteoporosis
• Swelling of arms or legs

Emotional and behavioral anorexia symptoms Emotional and behavioral characteristics associated with anorexia include:

• Refusal to eat
• Denial of hunger
• Afraid of gaining weight
• Lying about how much food has been eaten
• Excessive exercise
• Flat mood (lack of emotion)
• Social withdrawal
• Irritability
• Preoccupation with food
• Reduced interest in sex
• Depressed mood
• Possible use of laxatives, diet aids or herbal products

When to see doctor Anorexia, like other eating disorders, can take over your life. You may think about food all the time, spend hours agonizing over options in the grocery store and exercise to exhaustion. You also may have a host of physical problems that make you feel generally miserable, such as dizziness, constipation, fatigue and frequently feeling cold. You may feel irritable, angry, moody, sad, anxious and hopeless. You might visit pro-anorexia websites, refer to the disease as your "friend," cover up in layers of heavy clothing, and try to get by on a menu of lettuce, carrots, popcorn and diet soda.

If you're experiencing any of these problems, or if you think you may have an eating disorder, get help. If you're hiding your anorexia from loved ones, try to find a confidant you can talk to about what's going on.

Anorexia red flags to watch for It may be hard to notice signs and symptoms of anorexia because people with anorexia often go to great lengths to disguise their thinness, eating habits or physical problems.

If you're concerned that a loved one may have anorexia, watch for these possible red flags:

• Skipping meals
• Making excuses for not eating
• Eating only a few certain "safe" foods, usually those low in fat and calories
• Adopting rigid meal or eating rituals, such as cutting food into tiny pieces or spitting food out after chewing
• Cooking elaborate meals for others but refusing to eat
• Repeated weighing of themselves
• Frequent checking in the mirror for perceived flaws
• Complaining about being fat
• Not wanting to eat in public

Unfortunately, many people with anorexia don't want treatment, at least initially. Their desire to remain thin overrides concerns about their health. If you have a loved one you're worried about, urge her or him to talk to a doctor.

Causes

The exact cause of anorexia nervosa is unknown. As with many diseases, it's probably a combination of biological, psychological and environmental factors.

• Biological. There may be genetic changes that make some people more vulnerable to developing anorexia. However, it's not clear specifically how your genes could cause anorexia. It may be that some people have a genetic tendency toward perfectionism, sensitivity and perseverance, all traits associated with anorexia. There's also some evidence that serotonin — one of the brain chemicals involved in depression — may play a role in anorexia.
• Psychological. Some emotional characteristics may contribute to anorexia. Young women may have obsessive-compulsive personality traits that make it easier to stick to strict diets and forgo food despite being hungry. They may have an extreme drive for perfectionism, which means they may never think they're thin enough.
• Environmental. Modern Western culture emphasizes thinness. The media are splashed with images of thin models and actors. Success and worth are often equated with being thin. Peer pressure may help fuel the desire to be thin, particularly among young girls.

Risk factors

Certain risk factors increase the risk of anorexia, including:

• Being female. Anorexia is more common in girls and women. However, boys and men have been increasingly developing eating disorders, perhaps because of growing social pressures.
• A young age. Anorexia is more common among teenagers. Still, people of any age can develop this eating disorder, though it's rare in people older than 40. Teenagers may be more susceptible because of all of the changes their bodies go through during puberty. They also may face increased peer pressure and may be more sensitive to criticism or even casual comments about weight or body shape.
• Genetics. Changes in certain genes may make people more susceptible to anorexia nervosa.
• Family history. Those with a first-degree relative — a parent, sibling or child — who had the disease have a much higher risk of anorexia nervosa.
• Weight changes. When people lose or gain weight — on purpose or unintentionally — those changes may be reinforced by positive comments from others if weight was lost, or by negative comments if there was a weight gain. Such changes and comments may trigger someone to start dieting to an extreme.
• Transitions. Whether it's a new school, home or job, a relationship breakup, or the death or illness of a loved one, change can bring emotional stress and increase the risk of anorexia nervosa.
• Sports, work and artistic activities. Athletes, actors and television personalities, dancers, and models are at higher risk of anorexia. For some, such as ballerinas, ultrathinness may even be a professional requirement. Sports associated with anorexia include running, wrestling, figure skating and gymnastics. Professional men and women may believe they'll improve their upward mobility by losing weight, and then take it to an extreme. Coaches and parents may inadvertently raise the risk by suggesting that young athletes lose weight.
• Media and society. The media, such as television and fashion magazines, frequently feature a parade of skinny models and actors. But whether the media merely reflect social values or actually drive them isn't clear-cut. In any case, these images may seem to equate thinness with success and popularity.

Complications

Anorexia can have numerous complications. At its most severe, it can be fatal. Death may occur suddenly — even when someone is not severely underweight. This may result from abnormal heart rhythms (arrhythmias) or an imbalance of electrolytes — minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body.

Complications of anorexia include:

• Death
• Anemia
• Heart problems, such as mitral valve prolapse, abnormal heart rhythms and heart failure
• Bone loss, increasing risk of fractures later in life
• In females, absence of a period
• In males, decreased testosterone
• Gastrointestinal problems, such as constipation, bloating or nausea
• Electrolyte abnormalities, such as low blood potassium, sodium and chloride
• Kidney problems

If a person with anorexia becomes severely malnourished, every organ in the body can be damaged, including the brain, heart and kidneys. This damage may not be fully reversible, even when the anorexia is under control.

In addition to the host of physical complications, people with anorexia also commonly have other mental disorders as well. They may include:

• Depression
• Anxiety disorders
• Personality disorders
• Obsessive-compulsive disorders
• Drug abuse

Appointment

Treatment of anorexia is generally done using a team approach that includes medical providers, mental health providers and dietitians, all with experience in eating disorders.

Here's some information to help you get ready for your appointments, and know what to expect from your doctor and other health providers.

What you can do

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. If you can, try to recall when your symptoms began.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins and supplements that you're taking.
• Ask a family member or friend to come with you, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot. A family member may also be able to give your doctor a fuller picture of your home life.
• Write down questions to ask your doctor so that you'll remember to cover everything you wanted to.

Some potential questions you might want to ask your doctor or other health care provider include:

• What kinds of tests do I need? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• Is there a generic alternative to the medicine you're prescribing for me?
• Will my periods begin again?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask, don't hesitate to ask questions of any of your providers anytime that you don't understand something.

What to expect from your doctor Your doctor or other health care provider is likely to ask you a number of questions, such as:

• How long have you been worried about your weight?
• Do you exercise? How often do you exercise?
• Have you found any other ways to lose weight?
• Are you having any physical symptoms?
• Have you ever vomited because you were uncomfortably full?
• Have others expressed concern that you're too thin?
• Do you think about food often?
• Do you ever eat in secret?
• Have any of your family members ever had symptoms of an eating disorder or have any been diagnosed with an eating disorder?

Tests and diagnosis

When doctors suspect someone has anorexia, they typically run many tests and exams to help pinpoint a diagnosis, rule out medical causes for the weight loss, and also check for any related complications.

These exams and tests generally include:

• Physical exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; checking your skin and nails for dryness or other problems; listening to your heart and lungs; and examining your abdomen.
• Laboratory tests. These may include a complete blood count (CBC), and more specialized blood tests to check electrolytes and protein as well as functioning of your liver, kidney and thyroid. A urinalysis also may be done.
• Psychological evaluation. A doctor or mental health provider will ask about your thoughts, feelings and eating habits. You may also be asked to complete psychological self-assessment questionnaires.
• Other studies. X-rays may be taken to check for broken bones, pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities. Bone density testing may be done to check your bone health. Testing may also be done to determine how much energy your body uses, which can help in planning nutritional requirements.

Diagnostic criteria for anorexia To be diagnosed with anorexia, you generally must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.

DSM diagnostic criteria for anorexia are:

• Refusal to maintain a body weight that is at or above the minimum normal weight for your age and height
• Intense fear of gaining weight or becoming fat, even though you're underweight
• Denying the seriousness of having a low body weight, or having a distorted image of your appearance or shape
• In women who've started having periods, the absence of a period for at least three consecutive menstrual cycles

Some medical professionals believe these criteria may be too strict or don't accurately reflect symptoms in some people. Some people may not meet all of these criteria but still have an eating disorder and need professional help.

Treatments and drugs

When you have anorexia, you may need several types of treatment. If your life is in immediate danger, you may need treatment in a hospital emergency room for such issues as a heart rhythm disturbance, dehydration, electrolyte imbalances or psychiatric problems.

Here's a look at what's commonly involved in treating people with anorexia:

Medical care Because of the host of complications anorexia causes, you may need frequent monitoring of vital signs, hydration level and electrolytes, as well as related physical conditions. In severe cases, people with anorexia may initially require feeding through a tube that's placed in their nose and goes to the stomach (nasogastric tube). A primary care doctor may be the one who coordinates care with the other health care professionals involved. Sometimes, though, it's the mental health provider who coordinates care.

Restoring a healthy weight The first goal of treatment is getting back to a healthy weight. You can't recover from an eating disorder without restoring an appropriate weight and learning proper nutrition. A psychologist can work with you to develop behavioral strategies to help you return to a healthy weight. A dietitian can offer guidance on a healthy diet, including providing specific meal plans and calorie requirements that will help you meet your weight goals. Your family will also likely be involved in helping you maintain healthy-eating habits.

Psychotherapy Individual, family-based and group therapy may all be beneficial.

• Individual therapy. This type of therapy can help you deal with the behavior and thoughts that contribute to anorexia. You can gain a healthier self-esteem and learn positive ways to cope with distress and other strong feelings. A type of talk therapy called cognitive behavioral therapy (CBT) is commonly used. Therapy may be done in day treatment programs, but in some cases, may be part of treatment in a psychiatric hospital.
• Family-based therapy. This therapy begins with the assumption that the person with the eating disorder is no longer capable of making sound decisions regarding his or her health and needs help from the family. An important part of family-based therapy is that the family is involved in making sure that healthy-eating patterns are followed. This type of therapy can help resolve family conflicts and muster support from concerned family members. Family-based therapy can be especially important for children with anorexia who still live at home.
• Group therapy. This type of therapy gives you a way to connect to others facing eating disorders. And informal support groups may sometimes be helpful. However, be careful with informal groups that aren't led by a mental health professional. For some people with anorexia, support groups might result in competitions to be the thinnest person there.

Medications There are no medications specifically designed to treat anorexia because they haven't been found to work very well. However, antidepressants or other psychiatric medications can help treat other mental disorders you may also have, such as depression or anxiety.

Hospitalization In cases of medical complications, psychiatric emergencies, severe malnutrition or continued refusal to eat, hospitalization may be needed. Hospitalization may be on a medical or psychiatric ward. Some clinics specialize in treating people with eating disorders. Some may offer day programs or residential programs, rather than full hospitalization. Specialized eating disorder programs may offer more intensive treatment over longer periods of time. Also, even after hospitalization ends, ongoing therapy and nutrition education are highly important to continued recovery.

Treatment challenges in anorexia Some cases of anorexia are much more severe than others. Less severe cases may take less time for treatment and recovery. One of the biggest challenges in treating anorexia is that people may not want treatment, may think they don't need it or may be concerned about weight gain. And, some people with anorexia don't see it as an illness, but instead promote it as a lifestyle choice.

Even if you do want to get better, the pull of anorexia can be difficult to overcome. Anorexia is often an ongoing, lifelong battle. Although symptoms may subside, you remain vulnerable and may have a relapse during periods of high stress or during triggering situations. For example, anorexia symptoms may go away during pregnancy only to return once your baby has been delivered. Ongoing therapy or periodic appointments during times of stress may be helpful.

Home remedies

When you have anorexia, it can be difficult to take care of yourself properly. In addition to professional treatment, follow these steps:

• Stick to your treatment plan. Don't skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
• Talk to your doctor about appropriate vitamin and mineral supplements. If you're not eating well, chances are your body isn't getting all of the nutrients it needs.
• Don't isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart.
• Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.

Alternative medicine

Although alternative medicine hasn't been well studied as a treatment for people with eating disorders, some alternative treatments can help reduce anxiety. And, such treatments may help people with eating disorders by increasing a sense of well-being and promoting relaxation. Alternative treatments that have been shown to reduce anxiety include:

• Acupuncture
• Massage
• Yoga
• Meditation

Coping and support

You may find it difficult to cope with anorexia when you're hit with mixed messages by the media, culture, and perhaps your own family or friends. You may even have heard people joke that they wish they could have anorexia for a while so that they could lose weight.

So how do you cope with a disease that can be deadly when you may be getting messages that being thin is a sign of success?

• Remind yourself what a healthy weight is for your body, especially at times when you see images that may trigger your desire to restrict calories.
• Don't visit pro-anorexia websites. These sites can encourage you to maintain dangerous habits and trigger relapses. Anorexia isn't a lifestyle choice. It's a disease.
• Acknowledge that you may not always be the best judge of whether you're eating enough or are at a healthy weight.
• Identify problem situations that are likely to trigger thoughts or behavior that may contribute to your anorexia so that you can develop a plan of action to deal with them.
• Look for positive role models. Remind yourself that ultrathin models or actors showcased in women's magazines or gossip magazines may not represent healthy bodies.

If you're interested in joining a support group, ask your doctor if he or she knows if there's a group in your area, or call the help line for the National Association of Anorexia Nervosa and Associated Disorders (ANAD) at 630-577-1330. (This is a toll call.) You can also find information on the organization's website.

Prevention

There's no guaranteed way to prevent anorexia or other eating disorders. Primary care physicians (pediatricians, family physicians and internists) may be in a good position to identify early indicators of an eating disorder and prevent the development of full-blown illness. They can ask questions about eating habits and satisfaction with appearance during routine medical appointments, for instance.

If you notice a family member or friend with low self-esteem, severe dieting habits and dissatisfaction with appearance, consider talking to him or her about these issues. Although you may not be able to prevent an eating disorder from developing, you can talk about healthier behavior or treatment options.