Anorexia nervosa (Greek: "nervous loss of appetite") is a condition in
which patients -- 85% of whom are women -- have problems with severe weight loss,
self-restriction of food intake, increased physical activity, amenorrhea
(no menstrual periods) in affected women, and a distorted image of their own
appearance. The term "anorexia nervosa" was first used in the medical
literature in 1873, but descriptions of women -- and some men -- with these
symptoms date back to the sixteenth century. In the fourth century Blessila,
sister of a protege of St. Jerome, reportedly followed his advice to be "pale
and thin with fasting" and died as a result; she may have been the first
recorded case of death due to anorexia.
Symptoms and Signs
The criteria for diagnosis of anorexia nervosa are published by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (currently in its fourth edition, published in 2000). The weight criterion is based on the patient's age and height, and we usually use the body mass index, or BMI (weight (in kilograms) divided by height (in meters) squared), to decide if someone is severely underweight. For women in their late teens or older, normal BMI is between 19 and 25. A BMI of less than 18 worries us, and a BMI of less than 17.5 meets the APA criteria. (I have cared for patients with BMIs of 10-11. That is scary.) Anorexia is more common than many people believe -- as many as 1 out of 50 women will be anorexic by the APA criteria sometime in their lives. About 15% of anorexics are men.
Anorexia happens often in people who are better off economically. Although malnutrition is (much too) common among the poor, it's not usually voluntary like it is in anorexia -- but we do see many people who are not well off and who exhibit the signs of anorexia. Anorexia is seen in patients of all ethnicities: in North America many anorexic patients are Caucasian, but we also ssee more and more patients of African, Asian, and Hispanic/Latino ancestry. Anorexia is also more common in cultures where thinness is valued: Brazil has seen an increase in anorexia -- and deaths from anorexia -- as thinness has become fashionable there, and several European countries have mandated minimum BMIs for fashion models after the death of a few models from anorexia-related malnutrition. Anorexia in a patient can also be triggered by specific incidents, including being criticized by "friends" or even dumped by a significant other for being "fat", or a death in the family due to heart disease (which may or may not have been related to obesity), as well as stressors not directly related to the patient's weight, diet, or appearance. Sports participation is sometimes a risk factor for anorexia, but the risk seems to depend on which sports the patient plays. Anorexia is somewhat more common amongst ballet dancers and cheerleaders than among other athletes; some studies suggest that gymnasts are also at risk, but some suggest otherwise. Eating disorders also seem to run in families: this may be due to one patient influencing others in the family, but there may be a genetic connection as well.
Anorexia usually starts during the teen years or in young adulthood, but sometimes children start becoming anorexics as pre-teens. Although one of the diagnostic criteria is amenorrhea, children who have not yet started having periods may develop anorexia, and they come to our attention because they are not growing properly -- rather than actually losing weight at first, these children may just gain weight much more slowly than others their age, and may become shorter than their age peers as well.
Most often, anorexics lose weight by not eating as much as they need to eat. This may start gradually and not be noticeable at first, especially in someone who was initially overweight, comes down to a (truly) healthy weight range, and then just keeps on going. Sometimes weight loss begins as a patient becomes a vegetarian (this is not very common, and certainly not a reason for a healthy person not to be a vegetarian). As time goes on, patients will systematically eliminate "unhealthy" foods -- meaning anything containing fat or carbs -- from their diets, and develop a list of their own of foods they consider to be "safe". These "safe" foods have as few calories as possible, and include foods which anorexics believe to have "negative" calories, i.e. foods that contains fewer calories than the body needs to burn in the process of digesting the foods. (Such foods really don't exist, but many anorexics believe that they do.)
Besides restricting their food intake, many anorexics will exercise to help lose weight. This is not the 10-minute walk each day that too many of us call exercise, either: I have seen patients who ran 15-20 miles each day, and others who do 500 "crunches" at a time, sometimes more than once a day. Even an ordinary walk turns into a "power walk", and athletes who are anorexic will practice excessively. It's important to know that the APA definition of anorexia nervosa does not specifically include not eating -- it merely asks if the patient is refusing to maintain weight that is in the normal range for her age and height, even if it is at the low limit of normal. By this rule, someone who eats a "normal diet" but is underweight and runs 20 miles a day or works out for several hours each day is anorexic, since she is not taking in enough nutrition to provide for her body's needs and for the energy she burns off in exercise.
Anorexics become more and more obsessed with thinness as they continue to
lose weight. A hallmark of anorexia nervosa -- and an important part of
the APA diagnostic criteria -- is that the patient's image of herself
becomes distorted as the disease progresses: even though she may appear
to others as little more than skin and bones, she sees herself as fat and
denies that she has a problem despite all objective evidence to the
contrary. A well-done -- and scary -- illustration of this is in a TV ad
produced for the Swedish organization
Riksföreningen Anorexi/Bulimi-Kontakt, available on
Many anorexics will weigh themselves over and over again in a single day, even though weight changes in such a short time are due to changes in water and mineral balance and have almost nothing to do with nutrition. If they lose weight, they congratulate themselves briefly, then set a new and even lower goal weight for themselves. They will punish themselves and increase their efforts to lose weight if they see even the tiniest gain in weight.
However, an anorexic, especially one living with her family, often realizes that others will notice her severe and worsening weight loss and the small amount of food she eats and will take steps to prevent them from noticing. These may include:
She will also try to conceal her condition from medical caregivers, by
Another, and all too common, problem with anorexics happens when they make friends with other anorexics. This sometimes leads to their swapping tips and tricks on how to be and stay anorexic, and/or to competitions to see who can lose the most weight. This is sometimes a problem with group therapy for anorexia, although proper facilitation of therapy groups can keep some of this under control. The appearance of Web sites run by anorexic patients that give tips on how to be anorexic has made treatment of anorexic patients more difficult in recent years.
See my separate page on treatment of eating disorders.
The Long-Term Outlook
Anorexia is often a chronic disease. In long-term studies anywhere from 47-76% of patients recover eventually, but it can take months to years to get better even with treatment. In my experience (and bear in mind that I tend to get those patients that pose more problems than the average anorexic teenager), about 4 out of 5 anorexic patients never become sick enough to need hospitalization at all. Of those who are hospitalized, about 4 out of 5 are admitted only once and never have to be hospitalized again.
The 1 out of 25 who have to be hospitalized are a special problem. Although they are followed closely as outpatients -- usually by people like me who specialise in eating disorder treatment -- these patients usually need, and benefit from, intensive treatment in residential programs. Unfortunately, there are relatively few of these programs, and they are very expensive: typical residential programs last for 1-2 months, and are resource- and labour-intensive. I am not personally involved in any of these programs, but based on my experience in hospital and private practice I would guess that the fees these programs charge just about cover the cost of operations with little overhead or leeway. Many insurance carriers will pay only a fraction of the fees charged by the programs, since anorexia has historically been regarded as a psychiatric problem (which it certainly is) and not as a medical problem (which it also certainly is). This is starting to change, especially after court cases in recent years in which insurance companies have paid damages to the families of eating-disorder patients who were denied appropriate coverage, but this kind of change occurs very slowly.