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ANOREXIA NERVOSA | Anne-Bénédicte Damon MSc., Clinical Psychologist

Once upon a time, there was an ordinary girl, who had an ordinary family and went to an ordinary school. No- one in her circle of friends went to the school cafeteria for lunch – the food was considered unpalatable. An ordinary lunch would go like this : Amelia usually brought an apple, claiming she wasn’t hungry. Betty often had some kind of healthy salad. Caroline had a tiny pack of crisps and a diet coke. And Patricia, our heroine, brought a homemade sandwich, usually ham and cheese. Lunchtime was rife with gossip. Someone had broken up with her boyfriend. Someone had gone to the cinema with the class jock. Someone had gained a lot of weight recently. Someone had “Oh my hat, look at those huuge thighs!”. Someone “looked pregnant, although who would date her?”.  

By and by, Patricia began to wonder about herself. She looked into the mirror. “Do you think I’m fat?”, she asked. And because this is a fairy tale, she thought she heard: “Yessss!” And then came PE, and running, and the teacher yelling at her “Hurry up, Patty!”, but she heard ‘fatty’. So she started to refuse the sandwiches her mother prepared for her, and she now took a salad and a pack of crisps and an apple for lunch. When even that started to feel like too much, she only brought the salad, then the apple, then nothing, and she claimed she was just going on a little diet, and anyway, she was never hungry at lunchtime. And anyway, she couldn’t eat what her mother prepared — her mother was so not health-conscious! She was the type to wrap a lump of cheese in batter and fry it. All her friends commiserated and admired her willpower. She also started doing sit-ups at home – she’d heard they helped get rid of belly fat. At first, she did ten, then twenty, and soon she managed a hundred.

After about a month, she was really pleased to see she had lost a few pounds, but it didn’t feel like enough. Luckily, there was a marvellous magic portal called the internet, where you only had to ask a question and you got lots of advice back. So, she asked “How can I lose weight quickly?”, and she got a plethora of answers. Some of them did not appeal at all: “Just eat fewer sweets, exercise a little more, and you will lose little by little.” That was too slow, and she was already doing it. She had been hoping for something more like Alice’s potions —only she did not want to be taller or smaller, just thinner[1]. Other options sounded more promising. “Always have sugar- free gum on you.” “Drink a lot of water to fill you up.” “Make yourself throw up after your meals.” “You can buy laxatives OTC, and they work sooo well.” All this sounded like good advice, so she took it. And as promised, she became thinner and thinner. So thin that you could now see her ribs and her collarbone.

Even her friends were worried about her now. She was not, because she was still “fat” —when she saw herself in the mirror, she saw a fat lump. Even though she exercised for several hours a day, and ate almost nothing, she now could not lose any more weight. Her body was covered in fine hair. She was cold all the time. But it did not matter, because when she finally got thin, everything would be perfect. This story has no Prince Charming, no lavish wedding, no children, and no happy ever after.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), anorexia nervosa is defined by the following[2] :

  • Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
  • Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
  • Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

There are two subtypes:

Restricting type: this subtype describes a situation in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.  In the previous 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Binge-eating/purging type: during the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

This disorder is on the increase everywhere in the world, especially among women. About 0.9 to 1.5% of women suffer from it, as well as 0.2 to 0.3% of men. For many, it remains a mysterious disease — who would willingly starve themselves? And common preconceptions are numerous. Let’s try to deconstruct a few myths.

1. It’s a woman’s disease.

Although cases in women are more prevalent, an increasing number of men suffer from anorexia nervosa. 1 in 3 sufferers are now male. The disorder can manifest itself in different ways in men, though. Firstly, because the ideal male body is more about being lean and muscular than just thin, male anorexics tend to exercise obsessively and take various supplements, including protein shakes and steroids. Moreover, they will be slower to seek help, if they do at all, because of the stigma attached to having what is still considered to be a feminine illness. Anorexia in men, however, is often more severe than in women.

2. It’s a teenage disease.

It is true that most cases start between the ages of 14 and 16, but that is not always the case. Specialists see more and more children (under 10) suffering from anorexia. It can also start in adulthood, usually after a traumatic life event: burnout, divorce, accident, or even pregnancy. When it happens during adolescence or childhood, it can be particularly problematic, as it slows or stops growth. Teenagers prone to body image dissatisfaction, low self-esteem and perfectionism are more at risk, as well as those who practise hobbies such as ballet dancing, gymnastics or modelling. Parents have to be aware of the warning signs and be ready to act quickly, for although about 50% of teenage anorexics recover with treatment, there is still a 5% mortality rate.

3. It’s a new, “fashionable” disease, mainly caused by the media and social media.

Anorexia nervosa is as old as time. We have descriptions of people experiencing anorexia-like symptoms dating back to Hellenic (323 BC-31 BC) and medieval times (5th -15th century AD), usually aiming at purifying themselves through the denial of physical needs. In antiquity and medieval times, anorexia was usually related to spiritual pursuits and holiness. It is now known as “anorexia mirabilis”, or “holy anorexia”. One of the most famous examples is Catherine of Siena (1347–1380), who survived on the Holy Host and nothing else. There were “fasting girls” who became famous for surviving almost on air at least until the 19th century. Some well-known historical figures like “Sissi”, the Empress Elisabeth of Austria (1837-1898), also suffered from anorexia. The first “real” case of anorexia nervosa was described by the physician Richard Morton in 1689, and others were then described in the 19th century, simultaneously but separately, by Lasegue and Gull. It was not until the 1950s, however, that the disorder was clearly described and studied in depth.

This is not to say that the media and social media do not play a part in the current explosion of cases, firstly by offering, especially to children and teenagers, unrealistic body norms as models.  Secondly, social media is largely to blame for misinformation about the disorder, as in adverse advice, unhealthy comparisons and even the advent of “wannarexics” – young girls and women who decide to become anorexic and claim anorexia as a lifestyle.

4. It’s a question of weight.

It is not a question of weight. You can have a normal weight and suffer from anorexia. You can be overweight and suffer from anorexia. And you can be underweight and not suffer from anorexia.

Even further, the disorder itself is not all about weight. It is not only a question of losing weight, but more a question of control. Control over one’s body, one’s food intake, one’s life.

5. Anorexics hardly ever eat, and never eat junk food.

Most anorexics have a very low intake of food. They often see food as impure, as the enemy. However, there’s a type of anorexia with binging and purging, where the patient will ingest a large quantity of food and purge afterwards. Some people do eat junk food or sweets, and will survive on one bar of chocolate or one small burger a day – they are still anorexic. And although most anorexics abstain from drinking alcohol due to its high calorie content, some of them get all their calories from alcoholic drinks (“drunkorexia”).

What are the warning signs?

Let’s take a female teenager as an example, although the behaviours are similar in older adults:

  • The obvious one: she eats less and less at mealtime, pretends she’s too busy to eat with the family and asks to eat in her room.
  • She becomes very health-conscious – “Do you know how many grams of fat there are in this?”; “I don’t eat eggs anymore because they’re bad for your cholesterol”; “I don’t eat fish because of the mercury content.” She only wants to eat ‘lite’ food.
  • She has very strong – and false- beliefs on food, and how her body works.
  • She says she’s becoming a vegetarian or a vegan. (Which does not mean all vegan and vegetarian teens are anorexics).
  • She wants to control everything in the kitchen- she offers to prepare the meals, often very copious ones, and gets angry if her family does not eat them, although she only picks at them herself.
  • She eats normally at mealtimes, but she immediately disappears after the meal, and you hear the toilet flush.
  • She starts to wear baggy clothes.
  • She’s exercising more and more – she’s taken up running, does aerobic exercises in her room, asks for a gym membership.
  • She’s obsessed by people’s weight – comments on it all the time.
  • She says she needs to get slimmer – because everything will be all right then; people will like her, and she’ll be happy.
  • She buys diuretics, laxatives, slimming pills, enemas.
  • She drinks a lot – three, five or more litres a day, to fill her stomach.
  • She seems impervious to the cold and will go out in a mini skirt and crop top in winter (the cold burns calories).

Why my child? Why me?

The causes are usually complex — a combination of factors. Anorexia nervosa tends to run in families – grandparents, parents, siblings with the same disorder, or at least with another disorder such as depression, usually appear in the family tree. Studies have shown that female relatives of individuals with anorexia are 11 times more likely to develop anorexia than relatives of individuals without anorexia.

Environmental causes can be found, usually peer pressure or parental pressure. We know that girls and women with this disorder tend to be perfectionists and overachievers. They do well at school, get good grades, and are sometimes involved in time-consuming and body-centred activities such as dance, gymnastics or acting. Low self-esteem also plays a part.

Biological causes have been hinted at. Grey matter deficits in brain areas involved in emotion, motivation and goal-directed behaviour have been reported. Other evidence shows the restricting behaviours, associated with anorexia, may stem from an imbalance between inhibitory and reward systems.

What are the risks?

The immediate risk for children and teenagers is of stunted growth. Menstruation usually either does not start at all, or stops. There are, of course, a number of other short term consequences.

  • Weakness, lack of energy and fatigue, dizziness, fainting, anaemia.
  • Gastro-intestinal symptoms, such as bloating, abdominal pain, constipation. If vomiting is involved, there’s a risk of mineral imbalance, and also of oesophagal rupture.
  • Cardiac symptoms – slow or irregular heartbeat.
  • Skin symptoms – lanugo (a layer of fine hair growing on the body), dry, yellowish skin.
  • Other symptoms such as poor circulation, always feeling cold, shortness of breath.

Long-term consequences include:

  • Damage to the reproductive system if the disorder is untreated for too long. Even if the menstrual cycle is restored once they gain weight, infertility problems and pregnancy complications can occur.
  • Cardiovascular issues. In addition to the short-term consequences, anorexia can damage the heart structure, and even lead to cardiac arrest.
  • Neurological issues: severe anorexia can alter certain brain areas and cause nerve damage. It can cause confused thinking, irritability, peripheral neuropathy (numbness, pain, or weakness, usually in the hands or feet)
  • Skeletal problems: osteopenia or osteoporosis, brittle bones, increased risk of fractures, loss of teeth, loss of hair.

I’ve noticed something wrong – what do I do?

Most people suffering from anorexia will swear nothing is wrong at all – they’ll usually say they’ve gone on a little diet to fit in their swimsuit: “Everyone does it.” If a parent tries to change their child’s new eating habits, the teenager will get angry, and say “You want me to get fat”, or “You don’t want me to be happy”.

There is no ideal way to broach the topic of an eating disorder, but the less adversarial, the better. “I can feel that you’re unhappy about something. Would you like to talk to someone?” will work better than dragging the teen by force to the doctor. It is imperative to seek treatment as soon as possible. It will only get worse with time, and nobody can recover from anorexia alone. It usually takes a whole team involved, but the bare minimum is a GP who can monitor the somatic (physical) aspect, and a psychologist or psychiatrist to help with the mental one.

No one chooses to become anorexic, but no one will admit to needing treatment – or at least, almost no one, and not immediately, since denial is usually a very strong mechanism in anorexia patients. Recovery is possible, but the sooner it is treated, the better the prognosis.

[1] Lewis Carroll, Ali’s Adventures In Wonderland, (London: Macmillan, 1865)

[2] The American Psychiatric Association The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, 2022).

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