Alison was a 17-year-old high school student. She had always been shy and anxious, but was a high achiever. Over the course of three months, Alison’s parents noticed that she was rarely eating at home and was getting steadily thinner. They asked her about this, but she said that she was eating at school and on the way home with her friends. Some weeks later, Alison’s mother came upon Alison making herself vomit in the bathroom.
Alison broke down in tears and admitted that she had been deliberately starving herself because she was afraid of becoming fat and believed that she currently looked fat. She also said that several of her friends were doing the same thing and had offered her tablets which, they said, would make her thin. Alison was too frightened to take them as she had already fainted twice at school in the past week. She did, however, continue making herself vomit, up to four times per day.
Alison agreed to attend the family doctor, who established that Alison’s menstrual periods had recently stopped due to her rapid weight loss and that Alison probably had anorexia nervosa.
At any time, approximately 1%-2% of young women have anorexia nervosa, a serious but treatable mental illness that is three times more common in women than men.
Anorexia is characterized by deliberate weight loss so that body weight is at least 15% below expected body weight or the person’s body-mass index (BMI) is 17.5 or less (for people aged 16 years or over). A person’s BMI is calculated using the person’s weight (in kilograms) and height (in metres). The BMI is the weight divided by the square of the body height (i.e. kg/m2). A person who weighs 70 kilograms and is 1.8 metres tall has a BMI of 21.6.
BMIs between 18.5 and 24.9 are normal, with lower values indicating underweight and higher values indicating overweight or obesity (30 or over). These guidelines are not cast in stone, and many factors need to be taken into account when interpreting them, but a BMI of 17.5 or lower is generally one of the key features of anorexia.
In addition, weight loss in anorexia must be self-induced, chiefly through avoidance of "fattening foods." There may also be self-induced vomiting or purging, excessive exercising, and use of medication to suppress appetite and weight. Psychologically, there is body-image distortion and a dread of fatness.
Physically, anorexia causes widespread disturbance of body hormones leading to an abnormal absence of periods in women (amenorrhoea) and loss of sexual interest and potency in men. In younger people, puberty may be delayed. Other features include dry skin, fine "lanugo" hair, low heart rate, intolerance of cold, and the physical effects of repeated vomiting (e.g. pitted teeth).
The causes of anorexia are not fully known, but it can run in families. People with anorexia tend to have low self-esteem, anxious personalities, obsessive-compulsive traits, and sometimes a history of childhood abuse. Media pressures also create unrealistic body expectations, contributing significantly to the problem.
Anorexia is treatable. At the outset, it is essential that the person’s physical health needs are identified and addressed by their family doctor. From a psychological perspective, the Royal College of Psychiatrists in the United Kingdom has a useful list of "Do's" and "Dont's." The "Do's" include:
- Sticking to regular mealtimes.
- Taking small steps towards healthier eating (e.g. if you can’t eat breakfast, just sit at the table for a few minutes at breakfast time and drink a glass of water, and try to progress a little day by day or week by week).
- Keeping a diary of what you eat and your thoughts and feelings.
- Tring to be open about what you are or are not eating.
- Being kind to yourself.
- Understanding what a reasonable weight is for you.
- Reading stories of other people’s recoveries.
- Joining supportive self-help groups.
- Avoiding websites or social networks that encourage very low body weight.
- Weighing yourself more than once a week.
- Spending time checking your body and looking at yourself in the mirror.
- Cutting yourself off from family and friends.
Cognitive-behavioral therapy (CBT) is the psychological therapy most commonly used in eating disorders. This involves learning more about the disorder itself; understanding how to predict symptoms and when they intensify; keeping a diary of eating episodes, binges, purging, vomiting, and any likely triggers; working towards regular, healthier eating habits; changing the way you think about your behaviour, feelings, and symptoms; and dealing with day-to-day problems and challenges more positively.
Other forms of therapy, such as family interventions, can also help. Most people with anorexia are treated as outpatients but hospital admission may be needed if outpatient care does not produce sufficient benefit; mental or physical health deteriorates sharply; BMI falls below 13.5; or there is a significant risk of self-harm. Anti-depressant medications are sometimes used when there are features of depression or obsessive-compulsive disorder.
Between 40% and 50% of people with anorexia nervosa recover fully; up to 35% show significant improvement; and approximately 20% develop a chronic disorder, with variable course. Five percent die of complications of the disorder.
Treatment of anorexia can be challenging owing to late diagnosis, ambivalence about making change, and problems accessing specialist services. Early diagnosis and prompt treatment can, however, make an enormous difference with this complex, treatable disorder.
Kelly, B. (2017) Mental Health in Ireland: The Complete Guide for Patients, Families, Health Care Professionals and Everyone Who Wants to Be Well. Dublin: Liffey Press.