Anorexia Nervosa, commonly referred to as anorexia, is one of the most common eating disorders. Although anorexia can manifest in several ways, it is most often characterized by a distorted body image, an intense fear of weight gain, and difficulties maintaining an appropriate body weight for one’s height, age, and stature.
What Is Anorexia?
People with anorexia tend to place significant value on controlling their weight, shape, and size, often using extreme measures to prevent weight gain or to continue losing weight.
These efforts might include severely restricting the number of calories and the type of food they eat, controlling net intake by vomiting after eating or by misusing laxatives, diet aids, or diuretics, and/or exercising compulsively.
However, no matter how much weight is lost, the person will continue to fear weight gain.
Unbeknownst to many, a person does not need to be emaciated or underweight to suffer from anorexia. You often can’t even tell if a person is struggling with anorexia by looking at them. While the stereotypical portrayal of anorexia often emphasizes extreme thinness, studies have found that larger-bodied individuals can also have anorexia.
According to the DSM-5, to qualify for an anorexia nervosa diagnosis, an individual must have a significantly low body weight based on their BMI. As such, larder-bodied individuals with the same clinical profile are diagnosed with atypical anorexia nervosa (AAN).
Because atypical anorexia nervosa is perceived as less severe than typical anorexia nervosa, an AAN diagnosis may prevent larder-bodied individuals with severe restrictive eating pathology from accessing appropriate and immediate treatment.
Additionally, larder-bodied individuals often go overlooked or undiagnosed due to cultural prejudice against fat and obesity.
Research shows that larger-bodied patients with AAN are more likely to experience delayed diagnosis, misdiagnosis, longer symptom duration, and greater levels of unhealthy weight loss than their lower-weight peers (Chen & Gonzales, 2022).
Symptoms
The most common symptom of anorexia nervosa is severe restriction of food intake, often leading to significant weight loss. People with anorexia have an intense fear of gaining weight and a distorted body image, perceiving themselves as overweight even underweight.
Larger-bodied individuals with anorexia may still have a distorted perception of their body size and shape, perceiving themselves as larger than they actually are.
They often engage in extreme dieting, strict calorie counting, and restrictive eating patterns. They may also develop rituals around food, such as cutting food into small pieces or avoiding certain food groups altogether.
Other physical symptoms often seen in individuals with anorexia include: abnormal blood counts (i.e., anemia), fatigue, muscle weakness, insomnia and other sleep problems, dizziness and fainting, hair thinning, absence of menstruation, low blood pressure, dehydration, reduced sex drive, and gastrointestinal issues (i.e., constipation, acid reflux).
It is important to note that the symptoms can vary from person to person, and individuals with anorexia may not exhibit all of the typical symptoms.
How Symptoms are Experienced
Having intense fears of weight gain or being “fat”
Sarah, a 21-year-old with anorexia nervosa, provides a poignant depiction of her experience living with this disorder.
Sarah says, “I constantly feel fat, no matter how thin I get. The numbers on the scale dictate my worth, and I’m terrified of gaining even a single pound.”
Sarah’s statement reflects the distorted body image and intense fear of weight gain commonly experienced by individuals with anorexia nervosa. Despite being significantly underweight, she perceives herself as fat due to the cognitive distortion inherent in the disorder.
The preoccupation with numbers on the scale reflects the belief that thinness equates to self-worth, which drives her obsession with weight control.
Sarah’s words highlight the psychological aspect of anorexia nervosa, which significantly disrupts body image perception. Research has shown that individuals with anorexia nervosa often have an altered perception of their body size, leading them to perceive themselves as larger than they are in reality (Kostecka et al., 2019).
This distorted body image perpetuates the cycle of restrictive eating and intense fear of weight gain, as the individual strives to attain an unrealistic and unhealthy thinness.
Preoccupation with food and calories
Lisa, a 25-year-old struggling with anorexia nervosa, highlights the intense preoccupation with weight, food, and calories that is characteristic of individuals with anorexia nervosa.
She says, “Every bite I take comes with a flood of guilt and anxiety. I obsessively count calories, weigh myself multiple times a day, and spend hours researching the nutritional content of every morsel. It’s exhausting, but I can’t stop.”
She experiences overwhelming guilt and anxiety surrounding eating, which drives her to track and control every aspect of her food intake meticulously.
The constant monitoring of calories, frequent weigh-ins, and extensive research on nutritional content demonstrates the significant mental and emotional energy dedicated to maintaining strict control over her eating habits. Despite the toll it takes on her, Lisa feels trapped in this obsessive cycle.
Lisa’s words shed light on the obsessive thoughts and behaviors often accompanying anorexia nervosa. Scientific consensus acknowledges that individuals with anorexia nervosa are commonly intensely preoccupied with weight, food, and caloric intake (Calugi et al., 2018).
This preoccupation stems from a combination of factors, including an exaggerated emphasis on body shape and weight in society, distorted beliefs about food and its impact on the body, and the desire for control.
Research suggests that individuals with anorexia nervosa may exhibit cognitive biases related to food, leading to heightened attention to calorie counts and nutritional details (Wang et al., 2021).
Refusing to eat certain foods or food groups (i.e., no carbohydrates)
Rachel, a 16-year-old living with anorexia, reflects on her specific aversion to consuming carbohydrates, driven by the fear of weight gain.
She states, “Carbohydrates are my biggest enemy. I avoid them at all costs because I believe they will make me gain weight instantly. I feel guilty and anxious if I even think about eating bread, pasta, or anything with carbs.”
Rachel firmly believes carbohydrates are the enemy and sees them directly threatening her desired thinness. This avoidance of carbohydrates manifests the rigid food rules and restrictive eating patterns commonly seen in individuals with anorexia nervosa.
The guilt and anxiety she experiences when considering or encountering carbohydrate-rich foods highlight the deeply ingrained beliefs and emotional distress associated with her disordered eating behaviors.
Rachel’s words exemplify the distorted beliefs and fear of weight gain that underlie her avoidance of carbohydrates. While specific food aversions can vary among individuals with anorexia nervosa, restricting or eliminating entire food groups, such as carbohydrates, is not uncommon.
The fear of weight gain associated with carbohydrates can stem from a combination of factors, including societal pressure for thinness, personal body image concerns, and distorted beliefs about the impact of carbohydrates on body weight.
Although scientific research (i.e., Hanachi et al., 2019) has found that restrictive eating patterns, such as the avoidance of carbohydrates, can lead to severe nutritional deficiencies and impair overall health, Rachel’s underlying fears and beliefs surrounding carbohydrates inhibit her from restoring a healthy relationship with food.
While Rachel avoids carbohydrates, it is important to note that the specific foods or food groups avoided can vary among individuals, and not everyone with anorexia will avoid the same things.
Other food groups that individuals with anorexia may avoid include high-calorie or high-fat foods, sugary foods, and/or processed foods.
Denying feeling hungry or making excuses to avoid mealtimes or any situations involving eating
Alex, a 22-year-old battling anorexia nervosa, acknowledges his denial of hunger and the avoidance of mealtimes, both of which are common behaviors among individuals with anorexia nervosa.
He says, “I convince myself that I’m not hungry, even when my body is screaming for nourishment. I make excuses to avoid mealtimes, telling myself I’ve already eaten or that I’ll eat later. I also struggle to recognize when I’m truly hungry or when I’ve had enough to eat. It’s like I’ve lost touch with my body’s natural hunger cues.”
Despite experiencing physiological hunger signals, Alex convinces himself that he is not hungry, ignoring his body’s needs. Making excuses to skip or delay meals becomes a strategy to maintain control over food intake and uphold his disordered eating patterns.
This disconnection from the body’s natural hunger cues underscores the impact of anorexia on the individual’s perception and responsiveness to their physiological signals.
Alex’s statement illustrates the disrupted relationship between hunger perception and eating behaviors in anorexia nervosa. Research recognizes that individuals with anorexia nervosa often experience a diminished awareness of hunger and satiety cues, making it difficult to recognize and respond to their body’s physiological needs (Holsen et al., 2012).
This disconnection may stem from various factors, including psychological factors like body image distortion and the desire for control. Research also suggests that neurobiological mechanisms may impair hunger and satiety signaling in anorexia nervosa (Herbert & Pollatos, 2018).
The denial of hunger and avoidance of mealtimes further perpetuate the disordered eating patterns and can contribute to severe malnourishment and its associated health consequences.
Exercising excessively
Megan, a 35-year-old with anorexia nervosa, speaks on her excessive exercise behaviors, which are characteristic of anorexia nervosa.
She states, “I can’t go a day without intense exercise. It’s not just about burning calories; it’s also about feeling in control and punishing myself for any ‘slip-ups’ with food. I feel anxious and restless if I don’t engage in rigorous exercise routines, even if I’m physically exhausted.”
Her compulsion to engage in intense exercise extends beyond the desire to burn calories. It serves as a means to regain a sense of control and act as self-punishment for perceived dietary “slip-ups” or deviations from strict food rules.
Megan experiences anxiety and restlessness when she does not engage in rigorous exercise, indicating the strong emotional and psychological dependency she has developed on this behavior.
Megan’s words shed light on the interplay between excessive exercise, control, and self-punishment in anorexia nervosa. From a scientific perspective, excessive exercise is a common feature of the disorder and serves as a compensatory mechanism to mitigate the anxiety and guilt associated with eating.
Engaging in intense physical activity allows individuals with anorexia nervosa to burn additional calories, maintain control over their bodies, and punish themselves for perceived dietary “failures.”
The drive for excessive exercise in anorexia nervosa is complex and can be influenced by multiple factors, including the desire for weight loss, perfectionism, and the need to alleviate anxiety or guilt (Keyes et al., 2015).
Research suggests that neurobiological factors, such as alterations in reward pathways and neurotransmitter systems, may contribute to the development and maintenance of excessive exercise behaviors in individuals with anorexia nervosa (Scheurink et al., 2010)
Developing food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate)
Olivia, a 29-year-old battling anorexia nervosa, adheres to strict routines when it comes to eating, including specific food arrangements, bite sizes, and chewing patterns.
She says, “I have strict food rituals that I must follow. I arrange my food in a certain order, take small bites, and chew each bite a specific number of times. If I deviate from these rituals, I feel overwhelmed with anxiety and guilt. It’s like I’m trapped in a cycle of repetitive behaviors that I can’t break.”
Deviating from these rituals triggers intense negative emotions, such as anxiety and guilt. Olivia describes feeling trapped within a cycle of repetitive behaviors, indicating the rigid and compulsive nature of her food rituals.
These rituals can be seen as a manifestation of obsessive-compulsive tendencies and a need for control. Research suggests that individuals with anorexia nervosa often engage in ritualistic behaviors surrounding food as a way to cope with underlying anxiety, reduce uncertainty, or create a sense of order in their lives (Calugi et al., 2019).
These rituals may serve as a means to manage the anxiety and guilt associated with eating, providing a temporary sense of relief.
However, over time, they contribute to the maintenance of disordered eating patterns and hinder the individual’s ability to engage in flexible and intuitive eating.
Addressing the underlying anxiety, providing alternative coping mechanisms, and gradually challenging and modifying the food rituals are essential components of treatment interventions for anorexia nervosa.
Withdrawing from friends and social activities and becoming more isolated and secretive
20-year-old Michael highlights the social withdrawal and increased isolation he experiences from living with anorexia nervosa.
He admits, “I used to be outgoing and enjoyed spending time with friends, but now I find myself withdrawing from social activities. I feel ashamed of my eating habits and body, so I isolate myself and keep my struggles a secret. It’s like anorexia has turned me into a different person, and I’m trapped in this lonely and secretive world.”
Michael’s experience reflects the profound impact that anorexia nervosa can have on a person’s social life and interpersonal relationships.
The shame and self-consciousness associated with his eating habits and body image contribute to his decision to keep his struggles hidden, creating a sense of secrecy and loneliness.
Michael’s words illustrate the social and emotional consequences of anorexia nervosa, as individuals often withdraw from social activities and become more isolated and secretive about their struggles.
From a scientific perspective, social withdrawal in anorexia nervosa can be understood as a result of a combination of factors.
The shame and guilt surrounding disordered eating behaviors and distorted body image can lead individuals to isolate themselves as a way to avoid judgment or scrutiny from others.
Additionally, the preoccupation with food, weight, and body image can consume a significant amount of mental and emotional energy, making it challenging to engage in social interactions.
Research suggests that the neurobiological and psychological factors associated with anorexia nervosa, such as altered brain circuits involved in reward and social processing, may contribute to the social withdrawal observed in individuals with the disorder (Sidiropoulos, 2007).
Irritability
Emily discusses the heightened irritability and emotional volatility that she experiences as a result of her anorexia nervosa.
She states, “I’m always on edge and easily irritated. The smallest things can set me off, and I snap at people around me. It’s like my emotions are constantly boiling under the surface, and I can’t control the anger and irritability that consume me.”
Emily describes a constant state of being on edge and being easily triggered by even the smallest incidents, leading to outbursts of anger and snapping at others. This emotional turmoil significantly affects her interpersonal relationships and indicates the emotional dysregulation often associated with anorexia nervosa.
The underlying causes of these emotional disturbances are multifaceted and can be influenced by psychological and neurobiological factors.
Psychological factors, such as body image dissatisfaction, low self-esteem, and intense self-criticism, contribute to the emotional distress experienced by individuals with anorexia nervosa.
Neurobiological factors, including altered levels of neurotransmitters and disruptions in brain circuits involved in emotion regulation, may also contribute to the emotional dysregulation observed in the disorder (Lavender et al., 2015).
Recognizing and addressing the emotional challenges and implementing strategies for emotion regulation and coping are important components of comprehensive treatment approaches for anorexia nervosa.
Demographics
The disorder most frequently begins during adolescence and is most often seen in females as young women tend to be the most sensitive to thinness standards and societal appearance ideals.
Almost 80% of teenage girls in the United States report fears of gaining weight and of being in larger bodies (Kearney‐Cooke & Tieger, 2015), and around 50% of girls and undergraduate women report being dissatisfied with their bodies (Grabe, Ward, & Hyde, 2008).
The internationalization of “perfect body” ideals and body size stereotypes from the media have been found to begin when girls are as young as 3 years old (Dittmar, Halliwell, & Ive, 2006).
However, an increasing number of children and older adults are also being diagnosed with anorexia; this disorder can affect people of all ages, genders, sexual orientations, races, cultures, and ethnicities.
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