psychology essay on anorexia nervosa

HYPOTHESIS AND THEORY article

Is anorexia nervosa a disorder of the self a psychological approach.

• 1 Regional Expert Centre for Eating Disorders, Neurosciences Department, Psychiatry Section, University of Turin, Turin, Italy
• 2 Mind, Brain Imaging and Neuroethics Research Unit, The Royal’s Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
• 3 Psychology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada

The debate concerning the pathogenesis and the maintaining factors of eating disorders, anorexia nervosa in particular, is ongoing especially since therapeutic interventions do not result in satisfactory and enduring rates of remission. This paper presents a model for the pathogenesis of eating disorders, based on the hypothesis of a deficiency in the development of the self. We present the theory in light of new evidence concerning the role of attachment insecurity in the development and maintenance of eating disorders. In particular, we define the self in eating disorders in a comprehensive way by taking into account recent evidence from experimental psychology and neurobiology. The paper considers the development of the self in terms of its synchronic (i.e., experienced in the moment) and diachronic (i.e., experienced as continuous over time) aspects. Both synchronic and diachronic aspects of the self are relevant to the expression of eating disorder symptoms. Further, the maturation of the self is interwoven with the development of attachment functioning from infancy to adolescence. This interplay between these developmental processes of the self and of attachment could be crucial in understanding the pathogenesis of eating disorders. The final part of the paper suggests a neurobiological link between the theory of the self in the eating disorders and the spatiotemporal functioning of the brain. Disturbances in spatiotemporal functioning may represent the neurobiological pathway by which deficiencies in the self is related to attachment functions in individuals with eating disorders.

The Self in Anorexia Nervosa

Most theories on the pathogenesis and maintenance of eating disorders, including AN, have been based on cognitive-behavioral models that focus on maintenance factors such as high level of need to control eating, judging self-worth based on shape and weight, and dietary restraint ( Fairburn et al., 2003 , 2005 ; Murphy et al., 2010 ). Yet such models do not provide a pathogenic explanation including the experiential or phenomenological and interpersonal aspects of the disorder that are prominent in the clinical presentation and in clinical interactions. That is, those with AN often report: profound disconnection with their own emotions and body sensations ( Skårderud, 2007 ), difficulty in understanding their own and others’ internal experiences ( Rothschild-Yakar et al., 2013 ; Tapajóz Pereira de Sampaio et al., 2013 ), and problems in constructing a personal narrative over time, especially related to the disorder ( Oldershaw et al., 2011 ; Treasure, 2013 ; Lang et al., 2014 ). Further, in reaction to such patients, clinicians may experience troubling emotional responses including a sense of helplessness and anger ( Vitousek et al., 1998 ; Satir et al., 2009 ; Fassino and Abbate-Daga, 2013 ).

Given the limitations of current prominent theories of AN, and considering the context of the phenomenological and interpersonal nature of the disorder, we propose a theory of the self in AN in which the self represents the organizing function of the mind that when disturbed, will lead to and maintain the disorder. A fundamental tenet of this approach is that AN symptoms are a way of managing painful internal experiences related to a deficit of the self ( Tasca and Balfour, 2014a ; Williams et al., 2015 ).

In this paper we outline a theoretical model of eating disorders, and of AN in particular, in which we illustrate our conceptualization of the self, and define AN as a disorder of the self. We argue that deficits in the self are the basis of eating disorder psychopathology, and that these deficits can be understood at the neurobiological level and at the clinical-developmental level. The main focus of our model is on anorexia nervosa because in which a deficit of the self is more extensive and deep; nevertheless it is possible to extend our model to the other eating disorders. For instance, binge eating, which may be a means of regulating negative emotions in those with bulimia nervosa or binge-eating disorder can derive from a deficit of the self. Such a deficit in these individuals is related to problems in attachment and thus to emotion dysregulation that may be a precursor to binge eating ( Tasca et al., 2009a ). As a broad guiding principle, we will use attachment theory ( Bowlby, 1969 , 1973 , 1980 ) to anchor our presentation because it is an extensive and well-tested model of adult development and psychopathology ( Mikulincer and Shaver, 2010 ). We will briefly discuss treatment and research implications that are informed by our theoretical model.

A Definition of the Self

What exactly is the self? The self may be understood as an integrative structure of the mind that organizes and coordinates different functions (affective, cognitive, social, sensorimotor, and vegetative) with regard to interoceptive and exteroceptive stimuli from one’s own body and the environment ( Northoff, 2013 ). In this model, the self is the cognitive, conative, and affective representation of one’s subjective experience and one’s identity. Thus, the self plays an integral part in human motivation, cognition, affect, and social identity.

The self also implies a temporal concept. It extends across time from the past over the present and to the future. In contrast to the concept of identity, which describes the diachronic sameness of a person over time, the concept of self is synchronic, that is, it concerns the experience of an individual as him or herself, and allows him or her to attribute specific experiences, persons, or objects at a particular point in time ( Doering et al., 2012 ). This entails a self-specific organization of both neural and psychological activity ( Northoff, 2015a , b ). Alterations in the self-specific organization may consequently have an impact on all subsequent dependent functions, such as abnormal changes in affective, cognitive, sensorimotor, vegetative, and social functions.

Basic Deficit of the Self in Anorexia Nervosa

A number of years ago ( Bruch, 1982 ) proposed that at the root of AN was fundamentally a deficit of the self. As we suggested above, the integrative function of the self (i.e., its ability to integrate cognitive, affective, and conative functions) in those with AN is compromised. Bruch (1982) argued that individuals with AN function with a “false-self,” which implies that these individuals may not discriminate between their own and their caregivers’ expectations and needs ( Winnicott, 1964 ). More current conceptualizations indicate that individuals with an eating disorder are not able to discriminate between the sensations pertaining their body (e.g., hunger) and their emotions (e.g., anger; Skårderud, 2007 ). More importantly, and of particular relevance to our presentation, is the likelihood that their experience of their body is not integrated into their self. Even though patients with AN do not perceive their body as sharply extraneous, as sometimes happens in schizophrenia ( Northoff, 2015a ), they do appear to maintain an attitude of “objectification” toward their body, as if their body does not pertain to their self. The body is no longer experienced in a subjective way as “my” body, and thus as personal or self-related. Instead, the body is a mere object that is impersonal or non-self-related, with no special relationship to the self ( Greenleaf and McGreer, 2006 ; Fitzsimmons-Craft et al., 2011 ; Eshkevari et al., 2014 ). This is consistent with theories that suggest that physiological responses in the body are the origin of emotions. Such theories include both neuroscientific and philosophical concepts of embodiment of emotional feelings ( Northoff, 2012 ). Hence, those with anorexia nervosa may not perceive the physiological correlates of the body, and thus they may not experience, identify and express related emotions.

Bruch (1982) also suggested that the diachronic function of the self (i.e., the experience of a consistent self over time indicated by one’s identity) is interrupted. That is, the adolescent with AN has difficulty to consider their future and to perceive and integrate their past into a current narrative of the self. The impact of this deficit is that such individuals with AN will have problems integrating their own internal experiences within a meaningful narrative of the self as persisting across time. Such problems will result in an unstable identity. The unstable sense of self and identity weakens related functions like self-esteem, emotion regulation, and interpersonal effectiveness. Contemporary psychoanalytic writers have expanded on these concepts by discussing how problems in early caregiver-child relationships may lead to basic difficulties with identifying feelings and integrating them into a sense of self ( Granieri and Schimmenti, 2014 ). Such difficulties may also be associated with problems in using symbols to represent internal states, thus hampering the ability to construct meaning ( Lavender and Freedman, 2002 ).

A pervasive weakness of the integrative functions of the self may explain why certain personality traits that are common to AN become rigid, such as high harm avoidance, low self-directedness ( Fassino et al., 2002 , 2013 ), and perfectionism ( Wade et al., 2008 ; Hurst and Zimmer-Gembeck, 2015 ). These traits become stable during adolescence, play a key role in the maintenance of AN, and often remain even after recovery from the disorder ( Wagner et al., 2006 ). Moreover, a theory of deficits in the self’s functions is consistent with a multifactorial model of the development and maintenance of AN, since the self integrates various aspects of mental functioning.

Deficits of the self in those with AN likely have their origins in attachment insecurity ( Blatt and Blass, 1990 ; Tasca and Balfour, 2014a ; Gander et al., 2015 ), and also in other sociocultural factors (i.e., pressures to be thin, and internalization of the thin ideal), non-shared life events (e.g., traumatic experiences), and genetic vulnerabilities to being underweight ( Klump et al., 2009 ). Before discussing attachment theory in more detail as a framework for our model of the self in AN, we review theories and research on deficits of the self in AN. We argue that problematic functions of the self result in difficulties in integrating current self-image and in relationships with others, which may generate feelings of inadequacy and social insecurity. These feelings of inadequacy and insecurity are among the most enduring maintaining factors of eating disorders ( Fairburn et al., 2003 ; Arcelus et al., 2013 ).

The Relational Self and Attachment in Eating Disorders

Healthy individuals perceive a clear distinction between their body, their emotions, and relationships, and those that pertain to others ( Decety and Sommerville, 2003 ). The organizing function of the self permits one to perceive what is one’s own and what is the “other” ( Doering et al., 2012 ). In this sense, the self plays a relational function because it defines and differentiates the participants of a relationship, since no true “relationship” exists without a differentiation between self and other ( Erikson, 1968 ). Along similar lines, Schore (1994) discusses the self as developing within the context of an environment (i.e., parental caregiving and attachment), and as experience-dependent.

The relational self begins in infancy during the process of differentiation ( Mahler, 1963 ). Blatt and Blass (1990) reformulated Erikson’s (1968) developmental model to provide a useful developmental framework in which both the relatedness and the self-definition lines of development work in a dialectic process across developmental phases. For example: (i) developing a sense of trust in a caregiver during infancy (a relatedness function) (ii) allows one to achieve adequate autonomy of the self as a toddler (i.e., a self-definition element), which in turn (iii) creates the conditions for becoming a differentiated autonomous self during the latency period (i.e., self-definition), that later (iv) gives way to mutuality in early adolescence (i.e., a relatedness function). Ideally, these developmental processes become integrated in (v) a clearly defined identity during late adolescence or early adulthood.

A secure attachment with a caregiver in infancy provide the context within which these developmental lines and processes facilitate the emergence of a relational and autonomous self. Difficulties with attachment security among those with eating disorders may be associated with a history of trauma in childhood and adolescence, and may result in heighted eating disorder symptoms, alexithymia, and shame ( Franzoni et al., 2013 ; Tasca et al., 2013 ).

Bowlby (1969) described the attachment behavioral system (e.g., crying, reaching, crawling, and eye gazing) as an inborn process that increases proximity between an infant and caregiver especially during times of threat or stress. Caregivers may respond in various ways including by being optimally available, unavailable, inconsistent, or frightening. The repeated interactions between infant and caregivers that are set in motion by infant attachment behaviors become encoded in the implicit memory system of the child as internal working models of attachment that act as schemata for future relationships ( Siegel, 1999 ). Attachment patterns are often stable from infancy to adulthood, though changes are possible due to life events or changing interactions with attachment figures in adolescence and adulthood ( Pinquart et al., 2013 ). Individual differences in organization of attachment behavior are to some extent related to the responses of attachment figures. Children, adolescents, or adults who experience caregivers or attachment figures as not providing adequate security, emotional availability, and attunement may develop maladaptive dependency or detachment as secondary defensive strategies (i.e., attachment anxiety/preoccupation or attachment avoidance/dismissing, respectively) when faced with threat or stress.

The Adult Attachment Interview (AAI; George et al., 1985 ; Main et al., 2003 ) is the gold standard for investigating the attachment system in adults. The AAI and its concepts are important for understanding eating disorders because the AAI primarily assesses attachment states of mind. Of particular relevance to this presentation, the AAI allows one to code two scales specifically related to the self and its functions: Coherence of Mind and Reflective Functioning, each of which is described below. The AAI is a clinical, semi-structured interview focusing on the interviewee’s current mental representations of early attachment experiences (including the loss of loved ones and other traumatic experiences), and their influence and possible impacts on adult personality and behavior. Both the coherence of the interviewee’s memories reflected in their narratives, and the quality of their collaboration with the interviewer serve to inform one about the interviewee’s internal working models of attachment.

Among the AAI scales, the Coherence of Mind scale is the most relevant indicator of the speaker’s state of mind with respect to attachment ( Main, 2000 ). Coherence of mind is characterized by the interviewee’s ability to provide a relevant and cohesive narrative about their attachment experiences that is collaborative with the interviewer. The quality of coherent narratives is not diminished by: (i) intrusions of current emotions about the attachment relationships, or (ii) a defensive memory structure that results in very brief and incomplete recollections. Thus, coherence of mind may be related to the “narrative self” that may indicate the integration and stability of the self over time ( Jacobs et al., 2003 ). Poor coherence of mind represents a specific difficulty in creating a personal narrative of one’s own psychological and personal development. As such, adequate coherence of mind may be an indicator of the quality of the diachronic nature of the self, that is, an indicator of the stability of the self over time, and thus of the coherence of the interviewee’s identity. In two case presentations, Tasca and Balfour (2014a) argued that patients with eating disorders often show low coherence of mind when they report their life experiences, both in the clinical interview and in the AAI transcripts. Also, researchers indicate low levels of coherence of mind among individuals with eating disorders, including those with AN ( Ward et al., 2000 ; Fonagy and Target, 2006 ).

Reflective Functioning and the Self

Reflective functioning, which can be rated in AAI transcripts is an indicator of mentalization and is related to theory of mind ( Fonagy and Target, 2006 ). Interviewees’ responses to AAI demand questions such as: “why do you think your parents behaved the way they did during your childhood?” and “how do you think your childhood affected your adult personality?” are rated for the individual’s ability to understand their own mental states and the mental states of others. As such, reflective functioning is necessary for accurate empathy and to respond appropriately (i.e., to understand others’ mental states), and may be representative of a well-developed autonomous self (i.e., the ability to appreciate that one’s own mental state is unique from yet related to others’). Reflective functioning may be a proxy for the synchronous experience of the self (in contrast to the diachronic nature of identity indicated by coherence of mind). That is, reflective functioning may be an indicator of one’s sense of self as experienced in the moment and as separate but related to others. Research on eating disorders indicate that those with AN have particularly low scores on reflective functioning even compared to those with other psychiatric disorders ( Fonagy et al., 1996 ).

Attachment insecurity, associated with low coherence of mind and low reflective functioning, can be characterized as anxious (or preoccupied) or avoidant (or dismissing). Attachment anxiety is associated with a maladaptive upregulation of the emotional system, and a preoccupation with loss or abandonment in relationships. Attachment avoidance is associated with a maladaptive down regulation of emotions, and a tendency to dismiss the importance of relationships. Both attachment anxiety and avoidance are associated with increased psychopathology and poorer treatment outcomes ( Tasca and Balfour, 2014b ). The clinical relevance of attachment dynamics for individuals with eating disorders is underlined by the association between greater attachment anxiety and avoidance with negative affect, body dissatisfaction, and eating disorder symptoms ( Tasca et al., 2006 , 2009a ; Troisi et al., 2006 ; Illing et al., 2010 ). Moreover, notwithstanding the relevance of some personality traits for the expression of eating disorder symptoms ( Fassino et al., 2002 ), attachment insecurity is related to eating psychopathology independent of personality characteristics ( Abbate-Daga et al., 2010 ; Amianto et al., 2011 ). Nevertheless, substantial evidence of the specific relationship between attachment style, eating disorder diagnosis, and eating disorder psychopathology is still lacking, and more research is needed in this field ( Tasca and Balfour, 2014b ).

Attachment and Development Stages Related to the Self in Eating Disorders

We now turn to describing in more detail a developmental model, and how problems in individual development are associated with deficits in the functioning of the self among those with eating disorders. In this section, we will use the developmental model articulated by Blatt and Blass (1990) . As indicated, Blatt and Blass described a dialectic process across time in which relatedness-based and self definition-based developmental lines evolve mutually so that functions of the self, including identity, can form cohesively within the individual. Rather than focus on each of Blatt and Blass’s stages separately, we will contain our discussion to severe failure in the development of the self in eating disorders by focusing on three broadly defined lines or phases in childhood through adolescence: (i) the self definition developmental line, (ii) the relatedness developmental line, and (iii) identity development in adolescence as the culmination of the two developmental lines.

First Stage: Self Definition and Body

As indicated, the first developmental line we will discuss is associated with self definition in childhood. This period and developmental line is crucial for the experience of the “body self” ( Winnicott, 1964 ). The high level of difficulty individuals with eating disorders have relating to their body may be associated with a failure in this separation-individuation line of development ( Blatt and Blass, 1990 ). Children experience and internalize a progressive distinction between their body and their mothers’ body. During this period of childhood, the “body self” acts as an objective reference to the emerging and autonomous self of the child. Two components of this developmental process include: the establishment of a gratifying involvement with the caregiver, and the eventual experience of incompatibility of the gratifying involvement with the development of a differentiated and autonomous self ( Blatt and Blass, 1990 ). The ability of the caregiver to recognize the needs of the infant as differentiated from the caregiver’s self is crucial for the child to experience a distinction between his or her body from that of the caregiver. In this sense, it may be that the child needs to develop a sort of attachment to his or her own body, which is facilitated by the relationship with the caregiver who also recognizes his or her body as separate. Failing that, the child may perceive their body as if it was an object pertaining the external world instead of a substantial part of their self. A related phenomenon is Winnicott’s notion of the “false self,” which is a condition that is common in early childhood in which children perceive thoughts or desires of their caregivers as their own because they cannot distinguish them. Similarly, the work of Schimmenti and Caretti (2016) illustrates how neglectful or abusive caregiver-child relationships can lead to problems with relatedness and self-definition in the child. These involve multiple disconnections at the level of the self and relationships, which has implications for the experience of one’s body.

Among those with eating disorders, Stein and Corte (2003 , 2007 ) found a particular conflation of self-esteem as body esteem. They argued that individuals with an eating disorder use their body-image as a proxy for their self-concept. This may be due to a deficit in the development of the self-definition. A negative body image and a high number of negative self-schemas can be understood as the expression of internalized aspects of self that may set the stage for the subsequent development of an eating disorder ( Stein and Corte, 2003 ). In one study, self-schema as “fat” mediated the relationship between overall self-concept and eating disordered attitudes and behaviors in women with bulimia nervosa and AN ( Stein and Corte, 2007 ). Thus, a deficit in the development of the self caused by problems with body-self definition may represent a core element in the emergence of eating disorder psychopathology.

Second Stage: Relatedness and Others

The second line of development in which attachment influences the functioning of the self in childhood is the relatedness line of development ( Blatt and Blass, 1990 ). As indicated, in order to activate attachment and caring behaviors from caregivers, children enact proximity-seeking behaviors. The interactions with caregivers that are set in motion by proximity seeking are encoded into the implicit memory system as internal working models, which contribute to the development of the self. Experiences of trust between infant and caregiver and of mutuality later in childhood are necessary for attachment security, which is necessary for adequate affect regulation and the development of a cohesive identity. As we discussed previously, attachment concepts of coherence of mind and reflective functioning represent the diachronic and synchronous nature of the self, respectively. We argue that deficits in these areas lead to problems with a coherent self narrative (i.e., a self that is not experienced as stable over time, which leads to heightened insecurity), and with difficulties understanding one’s own mental states and appreciating mental states in others (i.e., leading to affect instability and deficits in empathy).

Children who experience their caregivers as emotionally available and loving develop an internal working model of the self as loved and valued, and develop a model of others as loving and safe ( Bowlby, 1973 ). When children experience their caregivers as inconsistent or unpredictable, neglectful, or rejecting children may develop attachment insecurity. This leads to a model of the self as unlovable, and a model of others as unloving or rejecting ( Bartholomew and Horowitz, 1991 ; Ward et al., 2000 ). Accordingly, the experience of the child as valuable, worthwhile, and lovable in the context of the relationship with a caregiver creates a positive cognitive set about the self that is carried into adolescence and adulthood. Instead, insecure attachment is associated with negative views of the self and low self-esteem ( Sharpe et al., 1998 ; Troisi et al., 2006 ), which in turn is a risk factor and a maintenance factor for eating disorders ( Fairburn et al., 2003 , 2005 ).

Third Stage: Identity and Adolescence

Finally we discuss the “identity” phase of development as described by Blatt and Blass (1990) . Identity as indicated by Erikson (1968) is a process of defining a unified self that is both separate from others without a sense of alienation, and connected to others without role confusion. In Blatt and Blass’ model, identity is the confluence of the self-definition and relatedness lines of development. Identity development typically takes place throughout adolescence and is a function of evolving attachment relationships with parents, emerging important relationships with peers, as well as the ongoing dialectic of self-definition and relatedness.

The ability to develop a cohesive identity is in part dependent on early attachment bonds with primary caregivers ( Jacobs et al., 2003 ). The attachment to a caregiver thus remains essential during adolescence. A secure attachment pattern encourages individuals to look for intimacy, protection, and dependence from caregivers as a regulatory function in response to environmental stressors ( Kenny and Hart, 1992 ). However, during late childhood and early adolescence, peer relationships begin to take more central roles in the development of self concept and self-esteem. In the course of preadolescence and adolescence, a heightened sensitivity to social and relational messages produces the need among adolescents to integrate new experiences, thoughts, and behaviors in relation to the self. The shift of emphasis from parental to peer relationships can put a strain on attachment relationships with primary caregivers, thus requiring adaptation in these attachment relationships.

Adolescence is also a time when changes occur to one’s body related to puberty, and concurrent structural changes that occur with maturation of the brain conditioned by sex hormones ( Herting et al., 2014 ). The result is a challenge to the emerging identity and to the adolescent’s ability to manage and regulate their emotions.

The availability of secure attachment bonds in adolescence promotes the regulation of the individuals’ emotions. This is crucial since the internalization of a positive self-concept implies the ability to be aware of one’s emotions, to experience strong emotions without disruption, and to engage in a thoughtful examination of situations from a state of calm reflection and reasoning ( Skowron and Dendy, 2004 ). As a consequence, a cohesive identity fostered by secure attachment promotes the active exploration and mastery of the environment, which is necessary for an individual to develop autonomous functions and intimacy in adulthood. Failure to experience one’s self as socially appreciated and lovable produces a specific vulnerability to disordered eating in adolescents ( Arcelus et al., 2013 ).

An incohesive identity in those with an eating disorder likely results in them feeling incompetent or inadequate. Stein and Corte (2007) found that women with bulimia nervosa and AN had fewer positive self-schemas, more negative self-schemas, and higher interrelatedness among their self-conceptions compared to a control group. In conditions of relational stress, individuals with a frail self or incohesive identity may activate secondary attachment behaviors associated with preoccupied or dismissing attachments. These individuals may try to maintain a strong dependence with caregivers, or keep a maladaptive distance with respect to caregivers ( Tasca and Balfour, 2014a ). For example, Gordon (2000) found that individuals with bulimia nervosa do not feel that they have the capacity to be in a relationship while remaining autonomous. Individuals with an eating disorder may have a difficult time in conceiving their personal value independent of caregivers ( Cozzi and Ostuzzi, 2007 ). Research evidence suggests that secure attachment to parents, with a balance between encouraging of autonomy while emphasizing connectedness, enables adolescents to develop a clear identity and a positive self-concept ( Holmbeck and Wandrei, 1993 ; Deci and Ryan, 1995 ).

As indicated earlier, the attachment concept of coherence of mind (i.e., the ability to construct a coherent narrative of attachment relationships and, therefore, of the self; Main et al., 2003 ) is indicative of a cohesive identity ( Doering et al., 2012 ). Cohesive identity is generally associated with emotional health and well-being, whereas instability is related to fragile self-esteem ( Kernis, 2002 ). Research has indicated that poor self-concept (i.e., low self-esteem, self-confidence, and stability of the self) has a direct negative impact on the development of a stable identity among those with eating disorders ( Tasca et al., 2009b ). Further, there is growing evidence that coherence of mind is compromised among those with an eating disorder ( Fonagy et al., 1996 ; Pedersen et al., 2012 ).

Individuals with eating disorders experience a deep discomfort due to the lacking sense of the self, which is based on their inability to perceive and integrate their body image and physiological responses, to regulate their emotions, and to experience a diachronic sense of their self. They organize their behavioral responses to control and reduce their deep discomfort using the management of eating behaviors ( Skårderud, 2007 ). This may result in eating disorder symptoms, as described by cognitive-behavioral, attachment, and psychodynamic theorists ( Fairburn et al., 2003 ; Fassino and Abbate-Daga, 2013 ; Tasca and Balfour, 2014a , b ).

Outlook – Self and Brain in Anorexia Nervosa

To summarize, we argue that there is value in understanding eating disorders, especially AN, as a disorder of the self and its functions. Previous studies found that patients with AN have functional and structural alterations in a wide network of brain areas, including the precuneus, DLPFC, cingulate cortex, insulae, temporal poles, thalamus, hypothalamus, caudate nucleus ( Amianto et al., 2013 ; Cowdrey et al., 2014 ), and hippocampus-amygdala complex ( Wittman et al., 2010 ). These brain alterations may occur at an early stage of the disorder and may overlap with the brain circuits related to attachment functions ( Riem et al., 2012 ), which may be associated with the onset of the disorder.

The self can be seen in term of its diachronic nature and as a synchronous experience. Recent research in neurobiology has found that both diachronous and synchronous aspects of self are represented in the temporal-spatial characteristics of the resting state of the brain ( Northoff, 2015a , b ), and both of which are likely disturbed in AN. Recent data showed that self-related processing strongly overlaps with and is predicted by the resting state activity ( Qin and Northoff, 2011 ; Whitfield-Gabrieli et al., 2011 ; Bai et al., 2016 ; Huang et al., 2016 ). This seems to be especially the case in midline structure as the core part of the default-mode network (DMN). Since various resting state networks including sensorimotor networks and DMN are altered in eating disorders, these may be closely related to the above described alterations in the self. This remains to be shown in the future, however.

With regard to diachronic functions and the self, one can argue that phenomenologically, individuals with AN have a difficult time integrating past and present into a coherent identity. In attachment terms, these problems are indicated by the low coherence of mind as assessed by the AAI (i.e., in problems with constructing a coherent narrative about attachment relationships). Neurobiologically, this may be evidence of what Northoff (2015a) called temporal dysfunction (see Northoff, 2015b for details) in the resting state of the brain, thus disrupting the perception of time and the integration of the self across past and present experiences.

With regard to synchronous functions of the self, individuals with AN appear to have difficulty in integrating current self functions into a synchronous experience so that the self and other are not well distinguished or integrated. In attachment terms one sees in these patients low reflective functioning and mentalization likely due to a disruption in the ability to appreciate the self and other as separate but related mental states. This in part may underlie the experience of body image distortion and body dissatisfaction. In neurobiological terms, this problem may be indicative of Northoff’s (2015b) notion of spatial dysfunction in the brain’s resting state, in which there is a maladaptive and almost exclusive focus on the self and perhaps a misperception of the body as not part of the self.

Clinically, our attachment-based model of the self in AN implies that clinicians must provide a therapeutic environment that aims to provide secure base ( Bowlby, 1988 ) from which patients with AN can learn to develop affect regulation abilities, reflective functioning related to one’s own and others’ mental states, and a coherent narrative of the self over time. The relevance of attachment dynamics in the development of the sense of self in those with eating disorders suggests that systemic and multidisciplinary approaches to treating eating disorders and their families (e.g., Lock and Le Grange, 2015 ) may be necessary to facilitate the development of the self. Such approaches may help to overcome the temperament and neurobiological distortions associated with attachment insecurity and problems with the self ( Lask, 2009 ; Treasure, 2013 ; Kaye et al., 2015 ; Abbate-Daga et al., 2016 ). A detailed discussion of these treatment approached goes beyond the aims of the present review.

In terms of research paradigms, our model suggests that those with AN will show disturbances in the brain’s resting state, and that these may be specifically associated with spatial functioning possibly related to experiencing one’s own body as an integrated aspect of the self, and temporal functioning possibly related to integrating the self in a coherent narrative over time.

Author Contributions

FA contributed to the ideation of the review, to the search of literature, wrote the paper, translated the paper in English Language, revised the drafts of the paper. GN contributed to the ideation of the review, to the search of literature, wrote parts of the paper and summarized it, revised the English Language, revised the drafts of the paper. GAD contributed to the ideation of the review, and revised the drafts of the paper. SF contributed to the ideation of the review, to the search of literature, revised the drafts of the paper. GT contributed to the ideation of the review, to the search of literature, wrote parts of the paper, revised the English Language, revised the drafts of the paper.

Conflict of Interest Statement

The handling Editor declared a shared affiliation, though no other collaboration, with several of the authors SF, GAD and FA, and states that the process nevertheless met the standards of a fair and objective review.

The rest of the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors wish to thank the Bank Fundation “Cassa di Risparmio di Cuneo” for the economic support to the cooperation between the research centres with the grant “Stimolazione Magnetica Transcranica in soggetti affetti da Disturbi Alimentari” of the “Programma Neuroscienze 2012.” GT was supported by a Research Chair funded by the Faculty of Medicine, University of Ottawa and Department of Psychiatry, The Ottawa Hospital.

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Keywords : anorexia nervosa, eating disorders, attachment, self, neurobiological pathway

Citation: Amianto F, Northoff G, Abbate Daga G, Fassino S and Tasca GA (2016) Is Anorexia Nervosa a Disorder of the Self? A Psychological Approach. Front. Psychol. 7:849. doi: 10.3389/fpsyg.2016.00849

Received: 15 January 2016; Accepted: 20 May 2016; Published: 14 June 2016.

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Copyright © 2016 Amianto, Northoff, Abbate Daga, Fassino and Tasca. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Federico Amianto, [email protected]

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• Open access
• Published: 11 December 2023

What kind of illness is anorexia nervosa? Revisited: some preliminary thoughts to finding a cure

• S. Touyz 1 ,
• E. Bryant 1 ,
• K. M. Dann 1 ,
• J. Polivy 2 ,
• D. Le Grange 3 ,
• P. Hay 4 , 5 ,
• H. Lacey 6 ,
• P. Aouad 1 ,
• S. Barakat 1 ,
• J. Miskovic-Wheatley 1 ,
• K. Griffiths 1 ,
• B. Carroll 1 ,
• S. Calvert 7 , 8 &
• S. Maguire 1  

Journal of Eating Disorders volume  11 , Article number:  221 ( 2023 ) Cite this article

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Two decades have elapsed since our publication of ‘What kind of illness is anorexia nervosa?’. The question remains whether our understanding of anorexia nervosa and its treatment thereof has evolved over this time. The verdict is disappointing at best. Our current gold standard treatments remain over-valued and clinical outcomes are modest at best. Those in our field are haunted by the constant reminder that anorexia nervosa carries the highest mortality rate of any psychiatric disorder. This cannot continue and demands immediate action. In this essay, we tackle the myths that bedevil our field and explore a deeper phenotyping of anorexia nervosa. We argue that we can no longer declare agnostic views of the disorder or conceive treatments that are “brainless”: it is incumbent upon us to challenge the prevailing zeitgeist and reconceptualise anorexia nervosa. Here we provide a roadmap for the future.

In our essay over two decades ago, we described anorexia nervosa as follows:

“ Anorexia nervosa is a mental and physical disease that was recognised in France in the 19 th century, usurped for England by Queen Victoria’s physician, and subsequently adopted by many thousands of Americans. According to the prevailing grand narratives embodied in DSM-IV and ICD 10, it is merely a part of the spectrum of eating disorders. This categorisation not only distorts our view of the illness, but also trivialises its seriousness (Beumont and Touyz [ 1 ] ) .”

It is not difficult to be disillusioned with our current concepts of anorexia nervosa (AN). Little has changed over the past 20 years since the publication of “ What kind of illness is anorexia nervosa? ”[ 1 ]. One incontrovertible fact about AN remains—it takes time to recover [ 2 ]. Despite decades of research into psychological interventions, and to a lesser extent pharmacotherapy, AN continues to have the sad distinction of having the highest mortality rate of all of the psychiatric disorders [ 3 ]. Researchers working in illnesses such as diabetes can point to their innovation in developing GLP1 agonists [ 4 ], and those in surgery to the advances in key-hole interventions [ 5 ] to manage, and in many cases even cure, people of their condition. Contrastingly, researchers and clinicians in the field of AN must accept that only 30 percent of those who survive the illness at ten years are fully recovered [ 6 ]. Schmidt and Campbell lamented that “ AN in adulthood remains markedly persistent and difficult to treat, with the holy grail of an effective, replicable outpatient treatment remaining highly elusive ” [ 7 , 8 ]. It is fair to say this picture is somewhat more optimistic for patients who are rapidly treated in adolescence, providing this treatment is in the outpatient domain where families are actively engaged in support of the young person’s recovery. Moreover, such family-based approaches can significantly reduce the need for inpatient treatment, the latter often associated with high rates of relapse and readmission to inpatient settings [ 9 , 10 ]. A precise explication for why treatment outcome in adolescence might be more favourable than in adulthood is complex. One hypothesis to consider here is that AN presenting in early adolescence is a ‘different’ syndrome than when presenting in adulthood in that the relational processes in adolescent AN are less compromised, which in turn makes recovery more likely [ 11 ]. Schmidt and Campbell [ 6 , 7 ] also drew attention to the lack of innovation in psychosocial treatments to date and felt it to be unlikely that any future breakthroughs in treating AN would emanate out of the talking therapies alone [ 8 ]. Kaye and colleagues (2015) have rubbed further salt into the wound by declaring that the field has fallen behind other psychiatric disorders in terms of the understanding of responsible brain circuitry and pathophysiology and agree that the treatment of AN can no longer remain “brainless” [ 8 , 12 ]. Bulik has further exposed this unpalatable truth by declaring that we have ‘…. not been paddling as hard as we can’ [ 13 ]. She later went on to say that the science of eating disorders has been held back by decades of “misunderstanding and misconceptions” and that there has been an ongoing promulgation of myths pertaining not only to the aetiology of AN, but as to the clinical effectiveness of treatment, as well as the prospects for recovery/cure [ 14 ].

There has been a proliferation of eating disorders in succeeding editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). It has grown from one diagnostic group to eight, and each warrants our attention [ 15 ], all contributing significantly to the burden of disease in eating disorders. But the profound suffering of those with severe and enduring anorexia nervosa (SE-AN) as well as the heavy financial load that it places on their carers continues unabated [ 16 ].

It is perhaps tempting to focus our energy on repairing over-burdened mental healthcare systems post COVID-19; however, the more vexing challenge is perhaps addressing the deeper malady at play which lies at the root of the problem: what exactly is AN? Is it a misperception of body image as Bruch alluded to [ 17 ], or a psychotic illness? [ 18 ]. Is it a phobia of normal body weight as Crisp described? [ 19 ]. Garner and Bemis [ 20 ] drew similarities between the severe psychological and physiological symptoms of malnutrition observed in the Minnesota Starvation Study [ 21 ] with those of the emaciated patient with AN, yet refeeding to the expected body weight rarely in itself guarantees full recovery from the illness [ 22 ]. Is it a learned habit as proposed by Strober, Walsh and Steinberg, and are such habits prone to consolidation during episodes of under-nutrition? [ 7 , 23 ]. The origins of this concept can be traced back to Montaigne who summarised this phenomenon better than most:

For in truth habit is a violent and treacherous schoolmistress. She establishes in us, little by little, stealthily, the foothold of her authority; but having by this mild and humble beginning settled and planted it with the help of time, she soon uncovers to us a furious and tyrannical face against which we no longer have the liberty of even raising our eyes (Montaigne (1580), in Graybiel [ 24 ] ) .

If neurobiological mechanisms are the root cause, will newer interventions such as temperament-focussed treatments be the answer? [ 12 ]. Are there data to refute some of these early propositions which might at least open the door ever-so-slightly for a reconceptualisation of AN? [ 25 ]. The room for growing our understanding of AN is boundless, but a shift in thinking is needed.

As early as 1985, Touyz et al. showed that those with AN did not misperceive or inaccurately distort their body image, but their persistent distress regarding their body shape was an affective over-evaluation rather than a factual distortion or visual misperception [ 26 ]. Yet this over-valuation of shape and weight has become the hallmark of AN and “such enduring wrong assumptions” are now being challenged [ 27 ]. Those with lived experience have been equal in their disdain regarding the social contagion of “body image” being at the core of this devastating illness. Such simplification of the complexity of AN becomes minimising, ultimately breeds stigma and misdirects the focus of research and clinical advancement. Bryant (2021), in her Lancet Psychiatry essay, has summarised this well when she asserts that “anorexia is an illness that blurs culture and pathology, and modern medicine still does not understand it” and that “the idea that something this powerful is merely a gesture of vanity is not only laughable, it is insulting” [ 28 ].

It is important to remember here that the earliest descriptions of AN by Moreton [ 22 ], Gull [ 29 ], and Lasegue [ 30 ] did not refer to any concerns about shape or weight, and it would therefore seem that that such a depiction of this illness is perhaps a more recent development in the history of AN [ 31 ]. Consequently, it has led to speculation that there could in fact be fat or weight phobic and non-fat phobic cases of AN [ 32 , 33 ]. Moreover, in a recent published study by our group, 5 of 21 AN patients admitted to hospital had beliefs of delusional intensity rather than merely having an over-valued idea [ 34 ]. To these arguments, one must add the important contribution of the Anorexia Nervosa Genetics Initiative (ANGI) study [ 35 ], which delineated many of what might be considered core symptoms of AN, but also came to the conclusion, albeit preliminary, that it was not only a psychiatric disorder but a metabolic one as well [ 36 ].

Is weight recovery from AN equivalent to actual recovery? Our group contrasted those who had gained significant weight (and can be considered weight recovered) to those who had in fact more fully recovered on several measures (including Eating Disorders Examination score and psychosocial adjustment) [ 37 ]. There were subtle differences between these two groups, suggesting the deeper more damaging psychological roots characteristic of AN had not diminished despite significant weight gain. There is an abundance of clinical confirmation as to the veracity of this contention, in that patients often allude to profound and life-disrupting distress caused by their persistent illness whilst at exactly the same time, their caregivers and families report their relief at the weight gain [ 38 ]. Caregivers and families, together with the therapeutic team appear unable to understand the overwhelming anxiety and phobic distress at the core of their loved one’s suffering has either remained constant, or at times even become exacerbated despite significant gains in weight. In many cases, they go on to lose weight again to alleviate and communicate that distress [ 38 , 39 ]. This is not to negate that weight gain is essential for recovery in the emaciated patient with AN, but unfortunately for many, weight recovery alone is not the silver lining as the “monster within” continues unabated.

We have also referred to a biological candidate marker for AN. In her ground-breaking ERP studies, Hatch et al. [ 40 ] was able to show that emotionally elicited ERPs pertaining to facial expression did not change throughout weight gain and remained depressed relative to controls. In not too dissimilar a vein, the over-active Default Mode Network (DMN) is now being targeted in innovative studies using psilocybin assisted psychotherapy [ 41 ]. Koning and Brietzke [ 41 ] in their narrative review on the potential role of Psilocybin Assisted Psychotherapy (PAP) in eating disorders, describe a 1959 French clinical case study of a patient with treatment resistant AN who received two doses of psilocybin. This resulted in her gaining insights into the root causes of her disorder with an almost immediate improvement in mood, and longer-term weight gain. They go on to provide a cogent argument that a disturbed neurotransmitter signalling may lie at the heart of the aetiology of this disorder. There is now emerging evidence to implicate both neurostructural changes in AN as well as abnormalities in reward and somatosensory processing networks [ 42 , 43 ]. Koning and Brietzke postulate that PAP may target many of the core aspects of AN including (a) serotonergic function, (b) abnormal eating behaviours, (c) depressive symptoms, (d) cognitive flexibility, (e) anxiety, (f) distress and avoidance of feared foods, as well as (g) acceptance of weight gain [ 41 ]. Much enthusiasm abounds with regards to psychedelics in the treatment of psychiatric disorders [ 44 ], however the clinical efficacy of these treatments remains to be determined and it is unlikely to be a panacea for “all that ails”.

The outcome data of such studies are eagerly awaited as they may identify critical differences in brain function in AN. As Kaplan points out “AN hijacks the neuronal system of the brain and pathologises it” (personal communication). Williams has started to map the brain circuitry in depression which could ultimately change the clinical landscape for that illness. For example, she refers to a large biomarker prediction study that indicates amygdala hyperactivation consistent with a negative bias biotype might help to delineate those patients who are less likely to respond to alternative types of antidepressants such as a dual-action serotonin–noradrenaline reuptake inhibitor [ 45 ]. Could the brain circuitry of AN be mapped in a similar way to that of depression? Both genetic and clinical research point to an almost hatred /disavowal of self, neophobia, unimaginable anxiety, intrapersonal and interpersonal distress, perseveration and rigidity, fear of failure, maturity fears, a disconnect between perception of illness severity and even impending death and a feeling of not deserving to eat, which are stoically defended despite evidence to the contrary [ 2 ]. As stated previously, at times these reach delusional intensity.

Our current treatments either focus disproportionally on overvaluation of shape and weight or on refeeding [ 22 , 46 , 47 ]. We accept both are essential for ultimate recovery. There are many clinical examples of AN patients who attain a normal weight who show a rapid and somewhat remarkable recovery after re-engaging with life as it was prior to weight loss. However, others struggle, despite having received evidence-based interventions and go on to progress to a severe and often enduring form of this disorder. What separates out the 30 percent who recover within 10 years from the 30 percent who require 10–20 years to achieve the exact same outcome, and the 40 percent who appear to never recover or die an often-tragic early death after years of suffering, for both patient and their carers? [ 6 ]. It does not seem implausible that the lengthy delay to full recovery after more than a decade of illness may indicate the brain healing itself, but only if an optimum weight is maintained whilst at the same time challenging the debilitating symptoms of the disorder. Such brain plasticity is now well known [ 48 ]. The time may have come to embark on a harm minimisation strategy [ 49 ] using universally accepted rehabilitation concepts (e.g., supported accommodation, recreational and vocational opportunities) as has been established for schizophrenia [ 50 ]. It may well be that those with SE-AN who appear to show a remarkable recovery after years of illness are in fact those who were able to realign their disrupted neuronal system by maintaining a more optimum weight and at the same time dealing with the core psychopathological characteristics of the disorder.

With recent developments in the study of genetics and epigenetics, metabolism, neural networks and personalised medicine [ 51 ], we are at the cusp of a paradigm shift which augers well for the future. For more than a century we have created a straw house, just like the three little pigs in the well-known children’s fable. This has served its purpose until now as clinicians have an imperative to treat and individuals with AN deserve nothing less than to be offered, at least initially, an evidence-based treatment. But these treatments continue to have modest recovery rates [ 6 ] and are wearing thin despite attempts to boost their clinical efficacy. How long will it take for the big bad wolf to come along and ‘huff-and-puff and blow the house down’? Only time will tell!

What will the future look like in the brave new world of eating disorders and how will we get there? The world recently witnessed the break-neck speed with which research related to COVID-19 was translated into practice [ 5 ]. With the will and appropriate funding, change can happen swiftly. The eating disorders field needs to build on the scientific foundations laid, and in many countries there are now ground-breaking research initiatives such as government-funded centres for excellence to enable this. This will ensure a sophisticated research infrastructure and workforce at the ready for the next exciting chapter in our understanding of what eating disorders are and how they can be best treated [ 52 , 53 ].

When it comes to the oldest eating disorder in the DSM [ 15 ], anorexia nervosa, it is “groundhog day”. We need to start again. However painful this may be, it must surely be done. This is not to throw the proverbial baby out with the bathwater – much has been achieved over the past decades including important theory developments and research demonstrating the safety of rapid refeeding without the over-arching nemesis of refeeding syndrome [ 54 ], or undertaking refeeding in the home environment [ 55 ]. But the well-worn assumption that AN is essentially a phobia about body image and that refeeding to a healthy weight constitutes full recovery should be reconsidered. AN is a complex psychiatric/metabolic disorder with roots firmly entrenched in early childhood characterised by a heightened degree of anxiety, lack of reward sensitivity, the avoidance of novelty seeking and a fragile self-esteem with a desperate need for sameness [ 56 , 57 , 58 , 59 ]. A marked fear of failure, and early indications of reluctance to engage in interpersonal relationships is at times confused by the suggestion that AN is somehow implicated in Autism Spectrum Disorder (ASD)—although this is not to say that some with AN may in fact have a dual diagnosis in this regard [ 60 ].

Although the Eating Disorder Examination (EDE) [ 61 ] has become the “gold standard” in the assessment of eating disorders and has enabled a high level of comparison between published studies, it has an unfortunate bias in that it conceptualises AN as a disorder with overvaluation of weight and shape at its core. The time has arrived to better delineate the phenomenology of AN [ 58 ], and then construct targeted treatments in the true spirit of precision psychiatry. To do so, a new multiaxial assessment instrument is needed that provides a comprehensive profile of each and every patient diagnosed with AN so that the complexities inherent in each case can be better evaluated and then targeted in intervention [ 62 ].

What would such a multiaxial assessment look like? What is needed is a scale that includes a comprehensive psychological profile of the core characteristics of AN, thus eliminating the need for the commonly used psychometric instruments such as the DASS, Beck Depression or Anxiety inventories, WSAS [ 63 , 64 , 65 , 66 ], self -esteem measures, perfectionism inventories, quality of life measures, to name just a few. We began this work developing the first co-designed (before the concept was fashioned) deep multi-axial assessment purely designed to measure the core psychological features of anorexia nervosa and assess their manifestation along severity axes providing a deeper understanding of the phenotype (the CASIAN; [ 67 , 68 ]. This work needs to be extended and broadened to include other parameters, although the second axis could measure the stage of illness as the illness changes with regards to severity over time [ 69 ]. The third axis may include the laboratory investigations routinely administered such as bloods, biochemistry, liver function, ECG and bone densitometry scans. A fourth axis could include brain circuitry based upon EEG and fMRI analyses. A biological candidate marker for AN already exists [ 40 ], and as this rapidly evolving phase of discovery gains momentum, this axis will come into its own. A further axis should provide a comprehensive neuropsychological profile based upon well-established research criteria developed by Tchanturia et al. and others [ 70 , 71 ]. Lastly, an additional axis devoted to functional outcomes is warranted. Improvements in everyday functioning are meaningful treatment outcomes for patients [ 72 ], and despite current illness, AN patients have enduring functional strengths which could be integrated into treatment [ 73 ]. What is so remarkable about AN is the oft-observed degree of resilience when it comes to academic achievement, or the ability to outperform others in a scholastic or work environment. This phenomenon has been noted in the genetic studies undertaken thus far [ 36 ], and although perfectionistic and maladaptive because of its extremes, does offer a strength to be better utilised in therapy.

Finally, the subtyping of restrictive versus binge/purge AN, which has been integral to each and every DSM iteration, may have reached its used-by-date. Although somewhat diligently recorded in almost every published study, and if not provided then without doubt would be requested during the review process, this distinction adds little to overall clinical care. Pierre Beumont was not only one of the founding fathers in the field of eating disorders, but a visionary scientist as well. While he was the first to point to the heterogeneity of AN and the need to subtype the disorder [ 74 ], a new subtyping is proposed here similar to an early model of depression [ 75 ]. A novel subtyping of reactive versus endogenous AN needs scientific exploration (Polivy, 2023 personal communication). It is proposed that in those patients with AN, where a clear precipitant is able to be identified (Reactive AN), existing evidenced-based treatments may be clinically effective; but, perhaps less so for those who have a more endogenous onset without an obvious precipitating factor or event (Endogenous AN). Patients with more complex presentations also appear less likely to respond to talk therapies, and may need a different, possibly more biological, approach. It is the latter group to whom the term “treatment resistant” is likely to be applied, with blame often attributed to the person with the illness. It is, however, the therapist who might be inadequate here, as the existing (psychological) treatments may not have the clinical power to effect change in this seriously ill and distressed cohort.

We cannot deny the indisputable fact that patients with AN continue to suffer (many for years and even decades) and die from this serious disorder. Patients in continental Europe have been approved for euthanasia and reports on “palliative care” are increasing. The desperate need to avoid further suffering is often openly expressed by those with a lived experience and their carers alike. However, others have expressed caution— asserting that in the absence of a clinically effective evidence-based treatment, it is unwise to talk about someone being treatment resistant, and further, that many patients with AN either receive no treatment at all − or at best inadequate treatment. Are these the advances we desperately wanted in our field in 2023? We suspect not. The time for complacency has ended and the need to find a cure for AN has arrived. We have brilliant minds at work, but rather than working in silos we need to work together with colleagues not just from inside our field, but also from outside our immediate field to finally put the conundrum of AN to rest. Bulik has likened the field of eating disorders to an island, suggesting we have not been “gregarious enough in engaging external scientists in our work” [ 14 ]. We also need to find ways to overcome the issue of under-funding in eating disorder research that contribute to the maintenance of the status quo [ 76 , 77 ]. It is now almost a century and a half since Gull [ 29 ] described AN, and those enduring the illness and their carers cannot wait any longer. We owe it to them.

So, what might the treatment of AN look like in a decade’s time? Kan and colleagues have given us a glimpse into the futuristic world of AN treatment and a possible roadmap to get there [ 51 ]. They provide a cogent argument that the time has now arrived to focus our research initiatives on developing new interventions that reduce the translational gap between emerging findings in neuroscience and the clinic. The days of agnostic assumptions in this regard are numbered.

Thus, we may need to tailor treatment and supplement intervention by targeting specific elements of risk and resilience. This would require a deeper phenotyping to examine facets of the core psychopathology including social and interpersonal function, reward reinforcement, anxiety sensitivity, cognitive styles and other biomarkers [ 51 ].

We encourage others to build upon this model or to provide alternative ones. Fernandez-Aranda and colleagues have already reminded us that “necessity is the mother of invention” and the aftermath of COVID 19 will no doubt lead to changes in our therapeutic models with the introduction of “more efficient and effective mixed methods of connection and a more personalized treatment palette as to what and how might work best for whom” [ 78 ].

So, what might the smorgasbord of innovative treatment modalities look like in the AN clinic of the future? Both Treasure et al. and Stengel and Giel have already begun to explore “emerging therapeutic targets” that could provide the armamentarium for treatment delivery in the next decade [ 79 , 80 ]. These will not only include the eating disorder phenotype such as cognitive, social and emotional difficulties, but also compounds other than olanzapine and antidepressants. The list grows longer day by day with further interest in lithium, ketamine, psilocybin, opioids, endocannabinoids as well as hormones such as oestrogen, histamine, oxytocin, leptin, growth hormone, ghrelin and nesfatin-1 [ 81 ]. These could be supported by innovations that better target eating behaviour habits and underlying processes that focus particular attention on implementation interventions, exposure-based therapies, inhibition training as well as disruptions to food cravings. Furthermore, neuromodulatory treatments that include non-invasive brain stimulation (NIBS) and deep brain stimulation (DBS) are being actively explored, however, caution should be exercised before we rush into interventions based on preliminary hypotheses or limited evidence. Further systematic research will be needed to determine the ultimate clinical success of these novel treatments, which must also be balanced by the risk of doing harm and making sure to adhere to the first rule in medicine “primum non nocere”.

Co-design is the new mantra of the day but rarely is it implemented in the manner that it was advocated and unfortunately tokenism abounds. Stengel and Giel so aptly point out that if our desired aim is to increase the acceptability and eventual adoption of novel therapeutics then “… it will be an important next step to increase integration of lived experience by patients and carers into the whole clinical research process” [ 80 ]. The status quo can no longer prevail. Science does not take kindly to attempts to change the existing zeitgeist but there now appears to be an unstoppable groundswell and determination to do exactly that in both our understanding and delivery of efficacious treatment(s) in AN. Existing clinical guidelines will become increasingly challenged and much careful thought and deliberation will need to be given to future iterations of DSM and ICD as the avalanche of new and exciting research findings come into play.

It is not expected that those who read this commentary will agree with all the propositions enunciated above, but it is hoped that it may spur others to action as it is likely to be a collective enterprise that ultimately bears the fruit of success. [ 16 ]. Opportunities for increasing research spending and providing opportunities for cross-collaborative research will go some way to enhancing translational research in the eating disorder field. However, any such enterprise must embrace the views of those with lived experience and their carers. They know better than most as to what this “monster within” does to often brilliant minds. We should refrain from our well-worn mantra of improving clinical effectiveness to the much loftier aspiration of finding a cure for AN. It is now within our grasp and time is of the essence. This journey has already commenced and the quotation from Noam Chomsky below should provide further impetus to realise this lofty aim.

“Optimism is a strategy for making a better future. Because unless you believe that the future can be better, it's unlikely you will step up and take responsibility for making it so. If you assume that there's no hope, you guarantee that there will be no hope.”—Noam Chomsky

Availability of data and materials

Not applicable.

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Acknowledgements

We would like to thank all those with lived experience who have shaped our understanding of this often-devastating illness. S.T. would like to acknowledge the important role that the late Pierre Beumont played in developing an understanding of AN. He was my mentor, colleague and friend and is sorely missed. We would also like to thank the anonymous reviewers for contributing their improvements to the manuscript.

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S. Touyz, E. Bryant, K. M. Dann, P. Aouad, S. Barakat, J. Miskovic-Wheatley, K. Griffiths, B. Carroll & S. Maguire

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ST: conceptualization, writing—original draft. EB and KD: writing—original draft, writing—review and editing and project administration. JP, DLG, PH, HL, PA, SB, JMW, KG, BC, SC: writing—review and editing. SM: writing—review and editing, and supervision. All authors contributed to the article and approved the submitted version.

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P.H. has received sessional fees and lecture fees from the Australian Medical Council, Therapeutic Guidelines publication, and New South Wales Institute of Psychiatry and royalties from Hogrefe and Huber, McGraw Hill Education, and Blackwell Scientific Publications, and she has received research grants from the NHMRC and ARC. She is Chair of the National Eating Disorders Collaboration in Australia (2019–) and an Editor in Chief of this journal. In July 2017, she provided a commissioned report for Takeda (formerly Shire) Pharmaceuticals on lisdexamfetamine and binge eating disorder, is a consultant to Takeda, and in 2018–2020 received honoraria for education of Psychiatrists. S.T. receives royalties from Taylor and Francis, Hogrefe and Huber and McGraw Hill for published book chapters. He has received honoraria from Shire/ Takeda Group of Companies for chairing the Australian Clinical Advisory Board for Binge Eating Disorder, public speaking engagements, commissioned reports as well as investigator- initiated research grants. He is an Editor in Chief of this journal, an inaugural committee member of the National Eating Disorders Collaboration, a Member of the Technical Advisory Group (TAG) on Eating Disorders (Commonwealth of Australia) and a member of the governing council of the Australian Eating Disorders Research and Translation Centre. DLG receives royalties from Guilford Press and Routledge, is Co-Director of the Training Institute for Child and Adolescent Eating Disorders, LLC, and is a member of Equip Health Clinical Advisory Board. The other authors have no conflicts of interest to disclose.

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Touyz, S., Bryant, E., Dann, K.M. et al. What kind of illness is anorexia nervosa? Revisited: some preliminary thoughts to finding a cure. J Eat Disord 11 , 221 (2023). https://doi.org/10.1186/s40337-023-00944-3

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• Eating Disorders

The Psychology of Anorexia: Understanding The Mindset

By: mackenzie wright | january 30, 2020.

Why would anyone deliberately starve themselves? This is something many people wonder when they think about anorexia. It's a question that people struggle with when watching their loved ones wasting away.

Anorexia is an odd condition because people suffering from it often don't want to get well. They don't want to be sick, of course; they don't want to feel lousy, damage their bodies, or die—but many struggle with a fear of getting better.

There are a host of different factors that may contribute to anorexia, from genetic to brain chemistry to social pressures. When it comes to psychology, though, many people with anorexia struggle to find the motivation to get well, because the motivation to keep things as they are seems stronger.

Life is unpredictable, and uncertainty can cause tremendous stress. Feeling helpless can be debilitating. Anorexia gives some people a feeling of control. This kind of power is addictive. The more researchers study people with the disorder, the more they are concluding that it's not about appearances as much as it is about control.

Distraction

One way to get relief from your fears and problems is to not think about them. By focusing intently on their eating habits and weight, they don’t have to think about other things. This obsessive-compulsive behavior becomes a defense mechanism.

Many studies have shown an overlap between eating disorders and obsessive-compulsive disorder. According to the American Journal of Psychiatry, more than 40 percent of people with eating disorders were also diagnosed with OCD.

Perfectionism

For some people, anorexia is driven by a desire to be perfect. It's not a drive to be perfect-looking—or at least, it doesn't end up that way. Most people with anorexia go far beyond looking perfect and quickly begin to look ghastly. They are more inclined to try and hide their ravaged bodies.

No, this kind of perfection lies in the perfect execution of a plan—and what makes it even better is that it's something most other people can't do, so there’s a minor ego boost bonus.

Emotional Release

Anorexia may have more in common with self-harm than most people realize. When people have trouble coping with problems, being close to death has a way of making one feel alive. The pain you suffer is cathartic; it helps you relieve just enough pressure to help you hang on.

The myth that anorexia is all about vanity is harmful. The root of the problem is not about vanity, it's about people having trouble coping with life. Once we understand that, it's easier to relate to those who suffer from the disorder.

Sources: Psychology Today, Scientific American

Photo: Pexels

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Anorexia nervosa.

Christine A. Moore ; Brooke R. Bokor .

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Last Update: August 28, 2023 .

• Continuing Education Activity

Anorexia nervosa is defined by the restriction of nutrient intake relative to requirements, which leads to significantly low body weight. Patients with this eating disorder will have a fear of gaining weight along and a distorted body image with the inability to comprehend the seriousness of their condition. This activity reviews the evaluation and management of anorexia nervosa and highlights the role of the interprofessional team in improving care for patients with this condition.

• Outline the epidemiology of anorexia nervosa.
• Explain the pathophysiology of anorexia nervosa.
• Describe the management of anorexia nervosa.
• Summarize the importance of improving care coordination among the interprofessional team members to enhance the delivery of care for those with anorexia nervosa.
• Introduction

Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image with the inability to recognize the seriousness of their significantly low body weight. [1] [2] [3]

The success of many professions depends on a person's weight. Models and actors portray a level of thinness that is difficult to attain, and it is enhanced by make-up and photographic alterations. Athletes in sports such as ballet, long-distance running, and martial arts are pressured to maintain lean body weights to outperform the competition. Media outlets promote diet secrets and weight loss tips in excess. Populations such as maturing females identify thin body types with increased self-esteem and link weight loss with self-control. [4] [5]

• Epidemiology

Anorexia nervosa is more common in females than males. Onset is late adolescence and early adulthood. Lifetime prevalence is 0.3% to 1% (European studies have demonstrated a prevalence of 2% to 4%), irrespective of culture, ethnicity, and race. Risk factors for eating disorders include childhood obesity, female sex, mood disorders, personality traits (impulsivity and perfectionism), sexual abuse, or weight-related concerns from family or peer environments. [6] [7] [8]

• Pathophysiology

Studies demonstrate biological factors play a role in the development of anorexia nervosa in addition to environmental factors. Genetic correlations exist between educational attainment, neuroticism, and schizophrenia. Patients with anorexia nervosa have altered brain function and structure there are deficits in neurotransmitters dopamine (eating behavior and reward) and serotonin (impulse control and neuroticism), differential activation of the corticolimbic system (appetite and fear), and diminished activity among the frontostriatal circuits (habitual behaviors). Patients have co-morbid psychiatric disorders such as major depressive disorder and generalized anxiety disorder.

• History and Physical

Patients will report symptoms such as amenorrhea, cold intolerance, constipation, extremity edema, fatigue, and irritability. They may describe restrictive behaviors related to food like calorie counting or portion control, and purging methods, for example, self-induced vomiting or use of diuretics or laxatives. Many exercise compulsively for extended periods of time. Patients with anorexia nervosa develop multiple complications related to prolonged starvation and purging behaviors.

Workup includes a thorough medical history (comprehensive review of systems, family and social history, medications including nonprescribed, past medical and psychiatric history, prior abuse) and physical exam (looking for complications above). Basic labs include coagulation panel, complete blood count, complete metabolic profile, 25-hydroxyvitamin D, testosterone (males), thyroid-stimulating hormone, and urine testing (beta-hCG [females] and drugs, either illicit or prescription). An electrocardiogram is recommended to assess for life-threatening arrhythmias. Additional studies may be necessary if BMI is less than 14 kg/m, for example, echocardiogram in patients with hemodynamic compromise (dyspnea, murmurs, syncope) or computed tomography of the abdomen to rule out superior mesenteric artery syndrome or amenorrhea more than 9 months (dual-energy x-ray absorptiometry). [9] [8]

Complications of anorexia nervosa are listed:

• Cardiovascular: bradycardia, dilated cardiomyopathy, electrolyte-induced arrhythmias, hypotension, mitral valve prolapse, pericardial effusion
• Constitutional: arrested growth, hypothermia, low body mass index (BMI), muscle wasting
• Dermatologic: carotenoderma, lanugo, xerosis
• Endocrine: hypothalamic hypogonadism, osteoporosis
• Gastrointestinal: constipation (laxative abuse), gastroparesis
• Hematologic: cytopenias (inc. normocytic anemia), bone marrow hypoplasia/aplasia
• Neurologic: brain atrophy, peripheral neuropathy (mineral and vitamin deficiencies)
• Obstetric: antenatal and postnatal complications
• Psychiatric: depression, impaired concentration, insomnia, irritability
• Renal and electrolytes: hypokalemic metabolic acidosis or alkalosis (laxative or diuretic abuse, resp.), prerenal renal failure, refeeding syndrome.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides the diagnostic criteria for anorexia nervosa (A-C). It classifies the disease by type, status, and severity.

Of note, amenorrhea has been removed from the DSM-5 criteria. Patients who meet the new criteria and continue to menstruate have similar outcomes as those who do not.

Other eating disorders have similar features to anorexia nervosa. Avoidant or restrictive food intake disorder involves food restriction with failure to meet the nutritional need. While patients are often underweight, this disturbance does not meet diagnostic criteria for anorexia nervosa. Individuals with binge eating disorder eat excessive amounts of calories in a short period with a lack of self-control but do not display compensatory behaviors such as purging or restriction. Patients with bulimia nervosa will binge and purge without a corresponding low BMI. Pica refers to chronic ingestion of nonfood substances and may be a manifestation of underlying medical or psychiatric condition. For example, patients with anorexia nervosa may eat toilet paper when they are hungry. Rumination disorder occurs when patients repeatedly regurgitate food for one month when no other medical condition can be identified and does not occur solely during the course of another eating disorder. Other specified feeding or eating disorder refers to conditions with symptoms that impair functioning but do not meet criteria for a specific eating disorder, for example, patients who meet criteria for anorexia nervosa but have BMI more than 18.5 kg/m are classified as “atypical anorexia nervosa.”

Major depressive disorder can cause anorexia and weight loss. However, patients are not obsessed with body habitus. Patients with obsessive-compulsive disorder may have food rituals but maintain a normal weight. Patients who abuse stimulants such as cocaine and methamphetamine experience weight loss through increased metabolism and concentrated efforts to obtain illicit substances rather than consume calories.

Medical conditions can cause weight loss. Examples are celiac disease, hyperthyroidism, inflammatory bowel disease, malignancy, poorly controlled diabetes mellitus, primary adrenal insufficiency, and tuberculosis. The diagnosis will come from the history and physical examination. Order labs as dictated by the clinical picture.

• Treatment / Management

Treatment for anorexia nervosa is centered on nutrition rehabilitation and psychotherapy. Patients who need inpatient treatment have the following characteristics:

• Existing psychiatric disorders requiring hospitalization
• High risk for suicide (intent with highly lethal plan or failed attempt)
• Lack of support system (severe family conflict or homelessness)
• Limited access (lives too far away to participate in a daily treatment program)
• Medically unstable (bradycardia, dehydration, hypoglycemia or poorly controlled diabetes, hypokalemia or other electrolyte imbalances indicative of refeeding syndrome, hypothermia, hypotension, organ compromise requiring acute treatment)
• Poorly motivated to recover (uncooperative, preoccupied with intrusive thoughts)
• Purging behaviors that are persistent, severe, and occur multiple times a day
• Severe anorexia nervosa (less than 70% of ideal body weight or acute weight loss with food refusal)
• Supervised feeding and/or specialized feeding (nasogastric tube) required
• Unable to stop compulsively exercising (not a sole indication for hospitalization).

Outpatient treatment includes intensive therapy (2 to 3 hours per weekday) and partial hospitalization (6 hours per day). Pediatric patients benefit from family-based psychotherapy to explore underlying dynamics and restructure the home environment.

Refeeding syndrome can occur following prolonged starvation. As the body utilizes glucose to produce molecules of adenosine triphosphate (ATP), it depletes the remaining stores of phosphorus. Also, glucose entry into cells is mediated by insulin and occurs rapidly following long periods without food. Both cause electrolyte abnormalities such as hypophosphatemia and hypokalemia, triggering cardiac and respiratory compromise. Patients should be followed carefully for signs of refeeding syndrome and electrolytes closely monitored.

Pharmacotherapy is not used initially. For acutely ill patients who do not respond to initial treatment, olanzapine is a first-line medication. Other antipsychotics have not demonstrated similar effects on weight gain. For patients who are not acutely ill but have co-morbid psychiatric conditions such as generalized anxiety disorder or major depressive disorder, combination therapy with selective serotonin reuptake inhibitors (SSRIs) and therapy is best. Patients who do not respond to SSRIs may need a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are less preferred due to concerns about cardiotoxicity, especially in malnourished patients. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures. [10] [11] [12]

• Differential Diagnosis
• Chronic mesenteric ischemia
• Malabsorption
• Hyperthyroidism
• Irritable bowel syndrome
• Celiac disease

Remission in AN varies. Three-fourths of patients treated in out-patient settings remit within 5 years and the same percentage experience intermediate-good outcomes (including weight gain). Relapse is more common in patients who are older with a longer duration of disease or lower body fat/weight at the end of treatment, have co-morbid psychiatric disorders, or receive therapy outside of a specialized clinic. Patients who achieve partial remission often develop another form of eating disorder (ex. bulimia nervosa or unspecified eating disorder).

All-cause mortality is greater in AN compared to the rest of the population. It has one of the highest mortality rates of all eating disorders due to medical complications, substance abuse, and suicide. Patients with AN have increased rates of suicide and this accounts for 25% of deaths associated.

• Complications
• Delayed puberty
• Hypercarotenemia
• Hypothermia
• Hypoglycemia
• Osteoporosis
• Failure to thrive 
• Cardiomyopathy
• Bradycardia
• Arrhythmias
• Renal failure
• Constipation
• Peripheral neuropathy
• Pancytopenia
• Infertility
• Deterrence and Patient Education

Anorexia nervosa is a psychiatric disease in which patients restrict their food intake relative to their energy requirements through eating less, exercising more, and/or purging food through laxatives and vomiting. Despite being severely underweight, they do not recognize it and have distorted body images. They can develop complications from being underweight and purging food. Diagnose by history, physical, and lab work that rules out other conditions that can make people lose weight. Treatment includes gain weight (sometimes in a hospital if severe), therapy to address body image, and management of complications from malnourishment.

• Enhancing Healthcare Team Outcomes

Anorexia nervosa is a serious eating disorder that has very high morbidity. The disorder is usually managed with an interprofessional team that consists of a psychiatrist, dietitian, social worker, internist, endocrinologist, gastroenterologist, and nurses.  The disorder cannot be prevented and there is no cure. Hence patient and family education is key to preventing high morbidity. The dietitian should educate the family on the importance of nutrition and limiting exercise. The mental health nurse should educate the patient on changes in behavior, easing stress, and overcoming any emotional issues. The pharmacist should educate the patient and family on the use of drugs like laxatives and weight loss pills. Only through close follow-up and monitoring can patient outcomes be improved. [13] [14]  [Level 5]

Evidence-based Outcomes

Remission in anorexia nervosa varies. Three-fourths of patients treated in out-patient settings remit within five years and the same percentage experience intermediate-good outcomes, including weight gain. Relapse is more common in patients who are older with a longer duration of disease or lower body fat/weight at the end of treatment, have co-morbid psychiatric disorders, or receive therapy outside of a specialized clinic. Often, patients who achieve partial remission develop another form of eating disorders like bulimia nervosa or unspecified eating disorder.

All-cause mortality is greater in anorexia nervosa compared to the rest of the population. It has one of the highest mortality rates of all eating disorders due to medical complications, substance abuse, and suicide. Patients with anorexia nervosa have increased rates of suicide, and this accounts for 25% of deaths associated with the disorder. [15] [16] [9]  [Level 5]

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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Criteria for Anorexia Nervosa Contributed by Christine Moore, D.O.

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Eating Disorders: Anorexia Nervosa Essay

People with eating disorders are characterized by unusual food intake behaviors. These individuals who suffer from eating disorders are at risk of dying, especially those who get diagnosed with anorexia nervosa (AN). The biological basis of existence of AN includes long-term determinants of Deoxyribonucleic acid that cause the body to lose weight but the patient overlooks the same. Anorexia is influenced by brain changes and genes, which comprise the biological basis of evidence regarding this eating disorder. People with anorexia nervosa are not highly interested in food and may be sensitive to the amount they take and the weight that may be gained. In terms of brain changes, anorexia is associated with the absence of gray and white substances in the brain where sulci enlarge for a person with the disorder, as shown in Figure 1 below (Carlson & Birkett, 2021). The brain tissue shrinks and catalyzes a person to ignore the impending dangers of their lifestyle when it comes to eating. In a healthy person who does not have the disorder, the tissue structures in the brain are normal, as shown in part B.

The other biological evidence is genetic factors that may influence anorexia nervosa. Between 58-76% of the variability in the diagnosis for anorexia is controlled by genes (Carlson & Birkett, 2021). For instance, children will inherit tissue formations in the brain from their parents, which may be easily affected by shrinking anorexia nervosa from their parents. (Schlegl et al., 2020). Genetic factors contribute to anorexia’s etiology due to the molecular approaches that are characterized by deterioration of physical health. The serotonin pathway receptors are essential in controlling molecular substrates that facilitate the physiology of food intake. Other crucial elements that are genetic include dopamine peptides that regulate energy intake and how it is consumed in the body (Schlegl et al., 2020). In this case, a person with genes that are receptive to dopamine-containing neurons may have this eating disorder. This disorder needs to be contained by utilizing cognitive behavioral therapy and pharmacological medications.

Carlson, N. R., & Birkett, M. A. (2021). Ingestive behavior. In Foundations of behavioral neuroscience (10 th ed., pp. 299–300). Pearson.

Schlegl, S., Maier, J., Meule, A., & Voderholzer, U. (2020). Eating disorders in times of the COVID‐19 pandemic—Results from an online survey of patients with anorexia nervosa . International Journal of Eating Disorders , 53 (11), 179-180. Web.

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Anorexia - List of Free Essay Examples And Topic Ideas

Anorexia nervosa is a severe eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of body shape. Essays on anorexia could delve into the prevalence, causes, and psychological, social, and physical impacts of this eating disorder. Discussions might also cover the treatments, the portrayal of body image in media, and the societal pressures contributing to anorexia. Analyzing the support systems, recovery narratives, and the ongoing research can provide a holistic understanding of anorexia nervosa and its profound impact on individuals and society. We have collected a large number of free essay examples about Anorexia you can find at Papersowl. You can use our samples for inspiration to write your own essay, research paper, or just to explore a new topic for yourself.

Effects of Anorexia Nervosa

Anorexia nervosa is one of the most commonly known eating disorder. It can occur in women and men including adults, kids, and teenagers. Anorexia is a ""mental disorder that is caused by the unsound terror of gaining weight. Anorexia nervosa is an ""emotional disorder characterized by an obsessive desire to lose weight by refusing food, commonly known as anorexia. Experts believe anorexia is caused by ""personality, genetics, environment, biochemistry, and overall emotional health. There are many horrific effects of anorexia […]

Anorexia Nervosa is a very Serious Eating Disorder

Anorexia Nervosa is classified as an eating disorder and a disease where individuals go through extreme measures to lose weight such as excessive workouts or extreme food diets in hopes to change their perspective on themselves. Individuals that embody this disease have a distorted body image of oneself and will still feel fat even after taking drastic measures to lose weight. These individuals think poorly and see themselves as overweight even if the individual is underweight. This has a lot […]

Eating Disorder is a Growing Problem in Modern Society

There are many misconceptions about eating disorders. One that stuck out to me is that people believe that eating disorders are a choice. Eating disorders arise from part of a person's genetic makeup and due to environmental factors. ( 'Eating Disorder Myths.') Their are many studies out their that help prove that eating disorders are often influenced by a person’s genes. Twin studies are useful in proving that eating disorders can be a family affair. ('Understanding Eating Disorders, Anorexia, Bulimia, […]

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Cause and Effect of Anorexia

The first time i ever heard about anorexia was from Degrassi: Next Generation. A character named Emma was trying to lose weight so she would barely eat and sometimes would make herself throw up. Being young I never really understood Anorexia, and the causes and how it can affect your body. According to experts, Anorexia Nervosa occurs in about 1 in 100 to 200 young women. Anorexia is an eating disorder that is also known as self starvation. It can […]

The Real Skinny on Anorexia a Merciless Battle with the Mirror

According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD) (2018), at least 30,000,000 people of all ages and genders suffer from an eating disorder at any given time in the United States. Of those 30,000,000, at least one person dies every 62 minutes as a direct result of their disorder. Most often, eating disorders affect women between the ages of 12 and 35. Compared to all other mental illnesses, eating disorders have the highest mortality rate (National […]

The Thin Documentary Analysis: Eating Disorder

Thin documentary is a film that follows four women at the Renfrew facility in Florida who are undergoing treatment for eating disorders. These women include Polly, Shelly, Brittany, and Alisa who range from 15 to 30 years old. The film follows them as they interact with their therapists, nurses, staff, other patients and with one another. Indeed, the documentary exploration regarding the struggles these anorexic women face in this institution in their attempt to improve and live a positive life. […]

Anorexia Nervosa: Literature Review

Anorexia nervosa, or better known as anorexia, is an eating disorder with which countless women and men battle every day, with worldwide prevalence. Anorexia is considered to be a psychiatric illness, which has long term effects on those who suffer from it, both psychologically and physically. The etiology of anorexia is multifactorial with genetic, biological, environmental, psychological and sociocultural influences. There are many different models of intervention to treat anorexia, which are each met with different measures of success. Social […]

Anorexia Nervosa: Serious Eating Disorder

Anorexia Nervosa is a very serious eating disorder that many people suffer from. People with Anorexia Nervosa go days without eating. People who suffer from Anorexia Nervosa have an intense fear of gaining weight. “The core psychological feature of anorexia nervosa is extreme overation of shape and weight”(“Anorexia”1). Even the people who suffer from Anorexia are very thin they still fear gaining weight. ¨The word ¨Anorexia¨ literally means ¨loss of appetite¨ (Watson, 7). Anorexia Nervosa is a coping mechanism for […]

Is there too Much Pressure on Females to have Perfect Bodies?

Have you ever felt insecure? It is very common for women in this society to feel that way.  It’s like everywhere you look there is pressure to look better or be skinny. Everything you do is being judged. Women are portrayed as fragile and delicate, but that is not always the case. Women are thriving in this generation and breaking down barriers of the norm. A big problem in society today that makes women feel insecure is advertising. Certain clothin […]

Anorexia: a Mental Disorder

Mental disorders are something that can be found in any human. One of the deadliest mental illnesses is anorexia nervosa. Anorexia nervosa is defined as a serious eating disorder that is characterized primarily by a pathological fear of weight gain leading to faulty eating patterns, malnutrition, and usually excessive weight loss. It has a higher mortality rate than any other mental illness. This disease affects people of all ages, races, genders, sexual orientation, and ethnicities. One in 200 American women […]

Anorexia: Symptoms, Causes and Risk Factors

The deadliest psychological disorder that has been studied is Anorexia Nervosa. This illness dates back to St. Catherine of Sienna in the 13th century and was originally considered a "wasting" disease. Mid-20th-century research by Hilde Bruch brought awareness to eating disorders, especially Anorexia Nervosa. Anorexia is rare but has the highest mortality rate of all psychological disorders and has high comorbidity with several other disorders like depression and anxiety. This disorder distorts how patients view their appearance, leading them to […]

Impact Media on Eating Disorders

With all of our current understanding so far we can see how much of an impact media has on triggering eating disorders. Research has only just begun to analyze the relationship between social media outlets such as facebook, body image and symptoms of eating disorders. Facebook is available at the fingertips of most adolescents today which allows them easy access to seek social comparison and negative feedback. Therefore it is an essential area to examine in relation to eating disordered […]

Anorexia and Bulimia

Introduction Anorexia and Bulimia are server disorders that is mostly found in girls. Anorexia has the highest mortality rate of any mental disorders, with an estimated 56 times more likely to commit suicide then those who do not suffer from anorexia (Tabitha Farrar, 2014). Being able to recognize the signs and symptoms of anorexia is very important, if recognized early treatment can be started quickly to better help these individuals sooner. Warning Signs Anorexia has many warning signs some of […]

Anorexia Nervosa: Common, Widespread Eating Disorder

Anorexia Nervosa is a very common, widespread eating disorder that affects individuals psychologically, emotionally, and physically. Those suffering from this eating disorder are commonly suffering from extremely low self-esteem and body weight. Individuals struggling with Anorexia typically fear to gain weight and are always conscious of what they are eating. They perceive their body as a distorted image, instead of viewing reality. Anorexia victims fear their body image as disproportional to their height and weight. An introduction to this disorder […]

What is Anorexia?

Anorexia is described by a distorted body figure, with a fear of being overweight or may some call it obese. Anorexia is commonly associated with women. Many signs of anorexia include low blood pressure problems, low electrolyte levels and being cold. Many tend to become binge eaters and have very bad behavior issues. Also people with anorexia tend to be excessive exercisers with lots of energy, have urges to feel unwanted and or left out. How does one find out […]

Anorexia Journal Article

Reading the journal article, it was apparent that the authors main purpose of this journal is the finding of a link between weight overestimation and disordered eating behaviors among normal weight women (Conley &Boardmen,2007).The authors go on further explaining how there is little to no research done with associating normal weight women and their possibility with acquiring an eating disorder because of how they might overestimate their weight and might be at risk of developing anorexia nervosa. The key concepts […]

Types of Eating Disorders and Treatments

Feeding and eating disorder affects more than 13% of men and woman coming from western countries (Reichenberg & Seligman, 2016). Out of that portion of the population, only about 40%-60% of those affected are said to be in remission from their disorder (Reichenberg & Seligman, 2016). There are many factors that come into play that contribute to the onset of such disorders including, family history, peer dieting, concepts of an ideal body, and some cultural considerations (Reichenberg & Seligman, 2016). […]

Negative Consequences of the Anorexia Fashion Research Argument Project

While Fashion Week is around the corner, the featured ""double zero sized models begin to prepare for the event by depriving themselves of all things indulgent to be as thin as possible. Fashion Week is an event where professionals from the fashion industry come together (usually in New York) twice a year to promote and display their latest creations of the season in a runway fashion show to buyers and the media. Models purge themselves in order to achieve this […]

Experience of Women who have Survived Anorexia

Anorexia is most commonly known as a fear of food and fear of getting fat. It usually begins in girls and women when they are young, often during adolescence or early adulthood. Some women I've mentioned in my essay will testify to their experience with anorexia. In my research, I found that much of adolescent and young adult anorexia can be attributed to social media and peer pressure at school. Social media can make women feel inadequate within just thirty […]

Anorexia is Primarily a Disease of the Nervous System

Eating disorder is a chronic clinical mental disorder that disrupts the psychological and social development of young people. Throughout research, it has been proven that face-to-face therapy is a better treatment than group treatments. Family-based treatment is a very effective treatment for teenagers who have anorexia. For family-based treatments, it has been proven that it is better for the parents to watch what their children are eating instead of having more multi-family settings. Another approach that has been studied is […]

Eating Disorders Anorexia

"Abraham, Suzanne, and Derek Llewellyn-Jones. ""Bulimia Nervosa.""Palla, Barbara, and Iris F. Litt. ""Medical Complications Of Eating DisordersIn Adolescents."" Medical Complications occur with eating disorders take place inanyones life. Adolescents being at such a young age if medical complications occur can affect them when they are older as well. For example, bulimia nervosa can mess with a young women's menstrual cycle and when they get older, they might not be able to have kids. This article will help when informing adolescents […]

Relationship between Depressive Disorder and Eating Disorder

Abstract Major depressive disorder (MDD) is a mood disorder characterized by intense and persistent feelings of melancholy and disinterest in regular activities for an extended period of time. Anorexia nervosa (AN) is a type of eating disorder categorized by significant weight loss, an intense fear of gaining weight, and a distorted perception of how one views their body shape or weight. These disorders frequently co occur with one another, in fact, according to a study posted on the National Eating […]

Anorexia Nervosa Eating Disorder

Anorexia nervosa is an eating disorder, characterized by the refusal of an emaciated individual to maintain a normal body weight (CITATION ENCYCLOPEDIA). More specifically, its diagnosis is based on three distinct criteria presented by the American Psychiatric Association (APA) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): First, consistent restriction of energy consumption resulting in a relatively low body weight must occur. Second, there is an irrational fear of weight gain. Finally, there is […]

Influences that Can Cause Anorexia Nervosa

Anorexia Nervosa is a psychological eating disorder that is the fear of gaining weight. People that suffer from anorexia eat very little food, which can then lead to starvation, or even death. There are many things that can influence anorexia, such as bullying, social media, stress, traumatic life events, and even low self-esteem. These things don't cause anorexia, but they are some of the strong contributing factors. Bullying Most people start to get bullied about their weight and size at […]

Anorexia Nervosa: Hunger and Satiety

Anorexia Nervosa is defined as a lack of appetite. It is a state of mind that makes the person affected believe that they are too fat and must lose as much weight as possible. ""People with anorexia generally restrict the number of calories, and the types of food they eat. Some people with the disorder also exercise compulsively, purge via vomiting and laxatives, and/or binge eat. (www.nationaleatingdisorders.org). It is a heart-breaking disorder and has affected millions of people every year […]

Randomized Controlled Trial of a Treatment for Anorexia and Bulimia Nervosa

Abstract The purpose of this study was to help treat patients with the illnesses of anorexia and bulimia nervosa and report their remission and relapse rates with a method of treatment in a randomized controlled trial. These eating disorders are major health problems that occur mostly in young women. Anorexia is when a person eats only small amounts of food while losing body weight, whereas bulimia is when a person eats large amounts of food and vomits immediately after to […]

Eating Disorder: Specific Model of Interpersonal Psychotherapy

Going off of these findings, Rieger et al. (2010) came up with an eating disorder-specific model of interpersonal psychotherapy. Due to the significance of social relevance in eating disorders, Rieger et al. laid out factors that played an important role in the development and maintenance of eating disorders. For example, a 2010 study of 208 patients who were diagnosed with AN or bulimia were assessed for interpersonal issues pre- and post-hospitalization. Eating pathology, symptom severity, and interpersonal patterns were examined. […]

Anorexia Nervosa: Abnormally Low Body Weight and Fear of Gaining Weight

""Anorexia Nervosa is an eating disorder that has abnormally low body weight and fear of gaining weight. People with anorexia care about what others think of them. Society plays a key role to people who have anorexia because; they put very thin people on the cover of magazines and advertisement. This causes individuals with anorexia to feel, un-pretty, rejected, and fat. This is all based on what the media puts out to the world. (works cited: 1). ""People with anorexia […]

Anorexia Nervosa and Bulimia

Introduction Anorexia Nervosa and Bulimia are serious disorders among our adolescent girls. According to the eating disorder hope website Anorexia has the highest mobility rate out of all mental disorders, it is important to recognize the signs and symptoms (Hamilton, 2018) so these girls can get the treatment they need. Warning Signs There are many warning signs to Anorexia and Bulimia. According to Nicole Williamson PhD at the Tampa General seminar, (May8, 2018) People with Anorexia might dress in layers, […]

The Movie Desperately Hungry Housewives Portrays the Struggles of Dieting and Anorexia

In the documentary, "Desperately Hungry Housewives," four women grapple with varying severities of dietary problems. Through a first-person perspective, they share their daily life and treatment options. These women provide a credible insight into the experience of handling dietary disorders in Britain as modern housewives. Besides showing how they managed their disorders, they also revealed the effect of these disorders on their children and how their families perceive the women themselves. Despite a lack of statistical data in the film, […]

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Anorexia Nervosa

Reviewed by Psychology Today Staff

Anorexia nervosa is an eating disorder and psychological condition marked by extreme self-starvation due to a distorted body image . People with anorexia think they are fat, regardless of how much they weigh, and are obsessive about monitoring their weight and the food they consume. They may regularly refuse to eat or eat only minimal amounts of food.

In spite of the health risks associated with being severely underweight, those with anorexia cannot see it as a problem. Yet those with the condition can and do starve themselves to death.

Anorexia is closely linked to perfectionism , depression , and suicidality . Although young women account for most cases, anorexia can affect anyone, at any time. But treatment can help individuals suffering from eating disorders make a lasting recovery.

For more on causes, symptoms and treatments, see our Diagnosis Dictionary.

• What Are the Signs of Anorexia?
• What Causes Anorexia?
• How Is Anorexia Treated?

Identifying eating disorders as early as possible is critical, because it raises the chance of a successful recovery. Although young women account for many cases of anorexia, the disorder can strike anyone, of any gender , race, or age. Symptoms encompass an altered relationship to food, weight, and exercise, whether that be severe weight loss, seemingly peculiar food choices, or an intense exercise regimen.

Warning signs of anorexia include rapid weight loss, an obsession with weight, food, or dieting , developing rituals and rules about when and what foods can be eaten, excessive exercise, eating alone and broader social withdrawal, and physical symptoms such as stomach pain, constipation, or exhaustion.

Women are three times more likely to experience anorexia in their lifetime than men. Older women also face eating disorders, and ethnic minority women and White women suffer from eating disorders at equal rates, research shows. Understanding who develops eating disorders can help people suffering come forward and help clinicians to recognize and treat the condition.

Anorexia and all eating disorders affect both psychological and physical health. Anorexia can lead to cardiovascular disease, osteoporosis, and gastrointestinal problems, including stomach pain, constipation, and vomiting. Anorexia can lead to hormone changes that stop menstruation, as well as the growth of fine “lanugo” hair on the body, dry skin, brittle hair, and more.

Yes. Eating disorders have the highest mortality rate of any mental illness. Research shows that about 10 percent of people with anorexia pass away. If you think that a loved one is in immediate danger, contact a helpline or call 911. Know that there are people who can help guide your loved one to recovery.

Five signs that children may be developing an eating disorder are: weight loss, unusual food rituals (cutting food into tiny pieces, using large quantities of condiments, insisting on particular cutlery), a sudden interest in cooking but not eating, compulsive exercise, and increased anxiety . If these behaviors occur, parents should broach the topic with their child and with their pediatrician.

Anorexia nervosa and other eating disorders are commonly found in cultures and settings where "being thin" is seen as desirable. Stressful life events can play a role in triggering the disorder, as can temperamental factors, such as perfectionism and obsessional traits. Biology and heredity seem to contribute to vulnerability as well, as individuals are more likely to develop the disorder if another family member has experienced it.

Anorexia emerges due to genetics , personality traits, and environmental factors. An individual is more likely to develop it if a family member has the disorder, showing its genetic underpinnings, while environmental influences such as stressful transitions and beauty ideals also contribute. Traits linked to anorexia include perfectionism, obsessiveness, and anxiety.

Anorexia cannot be definitively prevented, yet taking note of early warning signs can help. If someone struggles with self-esteem or body image , or begins a stringent diet, they may be on the cusp of developing an eating disorder. Discussing their emotions, providing support, and offering treatment options may prevent the condition from progressing.

Western culture tends to emphasize thinness and often equates it with beauty and success, which can conflate weight and self-worth. Research also finds that unlike other mental health conditions, celebrity disclosures of anorexia may actually increase traffic to pro-eating disorder websites. This may be because people struggling with eating disorders feel envy or admiration of the person’s “discipline” and thinness.

Eating disorders often don’t have to do with food as much as they have to do with concerns of self-esteem and control. Body dissatisfaction and low self-esteem can contribute to the desire to severely control food intake, as can trauma and stressful life events that seem overwhelming and uncontrollable.

People with anorexia may have diminished sensitivity to the internal cues that communicate hunger, research suggests, a phenomenon known more broadly as interoceptive awareness. They also show a stronger ability to delay rewards than those without an eating disorder. This combination may lead to a different experience of hunger—however people with anorexia still experience intense hunger.

Counseling and therapy, coupled with medical attention to health and nutritional needs, are important aspects of treatment. Treating anorexia involves three main goals : restoring weight lost to severe dieting and purging, treating psychological disturbances associated with body image distortions, and achieving long-term remission and rehabilitation or a full recovery.

Psychotherapy is the first-line treatment for anorexia. Cognitive behavioral therapy (CBT) and specifically enhanced cognitive behavioral therapy (CBT-E) involves recognizing and changing distorted beliefs that one has about eating and body image in order to ultimately develop normal eating patterns and arrive at a healthy weight. Family therapy is also widely used, as parental support is a key component of treatment and recovery for adolescents.

No medications specifically treat anorexia, but drugs may be prescribed to combat co-occurring problems such as depression and anxiety. Some drugs prompt weight gain, but none are currently approved to treat anorexia because patients rarely participate in these clinical trials and likely wouldn’t take medication without therapy to address underlying beliefs about body image.

People can be treated for eating disorders at an inpatient, residential, or outpatient facility based on their medical and psychological stability. Most people with anorexia are treated as outpatients, but hospital admission may be necessary if outpatient care doesn’t lead to sufficient change, if mental or physical health deteriorates sharply, or if there’s significant risk of self-harm .

Parents may be scared to raise the topic, but beginning the conversation can allow their child to heal. Parents can research eating disorders thoroughly, prepare what to say beforehand, communicate openly and honestly, avoid judgmental language, and encourage the child to seek professional help. In the case of an emergency, parents should seek medical attention or call 911.

Around 50 percent of people with anorexia nervosa fully recover and 35 percent show significant improvement. Approximately 20 percent will struggle with anorexia long-term, but with proper support and intervention there is always hope for improvement.

Recovery is a long, continuous process, throughout which relapse can occur. Elements of successful recovery include a strong support system and understanding the roots of one’s eating disorder, such as processing a trauma or developing healthy coping mechanisms for emotional distress.

From the crispy sweet taste of a caramel apple to a comfy sip of egg nog, treats can be delightful. Yet, how we relate to our treats can be tricky.

When assessing the influence of the wellness industry on eating disorders, some red flags in attitudes and behaviors need to be recognized and addressed to support recovery.

Discover the hidden risks behind popular recovery narratives and how thoughtful storytelling can offer true hope and healing.

A new “pre-publication study” suggests that separating “Do I want to write this book?” from “Should I publish it?” could be an important principle for the literary world.

My prior research findings on the effects of reading narratives about eating disorders made it important to ask difficult questions about the one I’d just written.

Personal Perspective: In 2015, I started writing a book based on this blog. It became a recovery memoir, but my prior research had raised serious ethical questions about the genre.

Research into eating disorders and mass shooters reveals a common thread—overvalued ideas that are relished, amplified, and nurtured online.

Do you say to yourself, "I feel so out of control around food"? This simple mind shift could help.

Diet culture pushes the narrative that thinner is better and that our worth is tied to our weight. Combating those ideas is vital for our mental and physical well-being.

Parents can guide eating disorder recovery with a home-based approach.

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