Anorexia Nervosa is probably the most well-known eating disorder. It accounts for 8% of all eating disorders in the UK (1). It’s estimated that 1.25 million people are currently living with an eating disorder in the UK (2). This statistic is likely very underestimated.
We know that around 75% of women are living with disordered eating at one time. And there’s a very fine line between eating disorders and disordered eating.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is what clinicians use to diagnose an eating disorder – we’re currently on the DSM-5. According to the DSM-5 Anorexia Nervosa can be diagnosed if the following criteria is met:
1. The person’s energy intake is restricted, leading to a significantly low body weight within the context of sex, age, developmental trajectory and physical health characteristics.
2. There is an intense fear of gaining weight or “becoming fat.’”
3. The person has a disturbed way of viewing their body. Perhaps they have a big emphasis on body weight or size, or they see themselves differently to what they look like.
Anorexia Nervosa is broken down into two subtypes: Anorexia Nervosa Restricting type and Anorexia Nervosa Binge-Purge type.
- Restricting type: Weight loss is accomplished primarily through dieting, fasting and/or excessive exercise.
- Binge-purge type: There are recurrent episodes of purging behaviour such as vomiting, over-exercising, laxative use, and/or diuretics
The 3-month period pre-diagnosis is normally taken into account.
Do you have to be underweight to have Anorexia Nervosa?
“Atypical Anorexia” is a term used to describe someone who meets the criteria, but is not in an “underweight” body.
Let me be clear: If you meet the criteria for Anorexia Nervosa, then you are living with it. It doesn’t matter what your body size is. Anorexia Nervosa is a mental health condition, it doesn’t matter the size of you body.
Sadly, the criteria for eating disorders is set in a world that discriminates between body sizes. As a weight-inclusive clinician, I don’t agree with the diagnosis “Atypical Anorexia.” In my books, if you have “Atypical Anorexia”, you are living with Anorexia Nervosa.
In fact, “Atypical Anorexia” is not atypical. Less than 6% of those with eating disorders are underweight.
Studies have shown that there is little to no difference in the psychological and physical impacts of anorexia and atypical anorexia especially in regards to morbidity (4). It is experienced the same by the body, but chances are if you are not significantly underweight you may be dismissed as “not being thin enough” to be experiencing anorexia. This is a dangerous idea that has been around for a long time.
Any age, gender, ethnicity, health or social status can experience anorexia, just like any eating disorder.
Why does Anorexia Nervosa develop?
There is no single cause of anorexia nervosa. The disorder may be a coming together of a lot of factors, and for many is triggered by a traumatic life event or social experience e.g. death of a loved one, or athletic competition.
Factors that influence AN can include
- Biological: age, gender, puberty and race. AN usually develops during puberty, but can occur at any age. Often it may occur during puberty due to the change in hormones coupled with changes in body shape / size that comes with this time of life. People of colour are significantly less likely to receive help for their eating disorders, despite reporting just as high rates of incidence.
- Environmental or social: family interactions, adverse life effects, athletic competition and culture. We currently live in a culture that glorifies the ‘thin ideal’. Repeatedly seeing adverts, TV shows, magazines and social media feeds full of those who represent this ideal can lead to our brain believing this is what we should look like.
Adverse life effects can include past trauma, with a growing body of research implicating child abuse and incidence of anorexia nervosa later in life.
- Psychological: negative emotionally, impulsivity and perfectionism. Perfectionism is well linked to eating disorders – and is referred to as clinical perfectionism when it becomes dysfunctional.
- Genetic: some studies have found increased rates of eating disorders in relatives of those experiencing an eating disorder – up to a 7-12 fold increase. But family members often share the same environment / family culture so it’s hard to say genes play a major role.
- Behaviours and perceptions: dieting, weight concern and negative body image. These practices compound to skew how you think of your body and your weight. As you focus on your weight and embark on a diet your body image becomes more negative, causing you to diet harder and focus more on your bodyweight… this cycle continues.
Some papers theorise that it’s the biological, environmental / social and genetic factors interacting with psychological factors and perception. This may be why individuals suffer for a long time before seeking treatment or being diagnosed.
If you are someone with perfectionist tendencies suffering with AN you are able to maintain a large amount of your life e.g. school work, social activities, employment before the disorder becomes serious enough to majorly impact these things. You may not even realise how severe the disorder is until this point, until you stumble upon someone else describing their situation or find a quiz online.
How is Anorexia Nervosa diagnosed?
Seeking support if you’re worried you may have anorexia will help start treatment as soon as possible if needed.
It is normally recommended you first contact your GP who will chat through your eating patterns and exercise history among other health indicators (such as menstrual status, body image, blood tests) and in the case of purging type AN they will check on effects of laxative abuse, pills, self-induced vomiting etc.
Anorexia is normally diagnosed via the DSM-5 criteria, and often uses BMI as an indicator but other tests may also be taken for diagnosis.
If you are worried about seeking GP support there are online services that can coach you through the process – but most services will work in conjunction with a healthcare professional to ensure you get the support you need.
What is the support for Anorexia Nervosa?
1. Referral to a specialist – if your GP does not recommend this, it may be that you request such a referral (especially if you are considering atypical AN).
2. Attending a specialist referral appointment
Know that at any of these steps a waitlist might be in place, especially with eating disorders on the rise. In fact, some waitlists on the NHS are up to three years.
What are the different treatment routes for Anorexia Nervosa?
When accessing treatment there are a range of different treatment options, and you may explore a few before finding what works best for you.
If your condition is very serious you may be admitted to hospital and undergo inpatient care to ensure your weight is restored before looking into other treatment options. Otherwise you may have the option of in or out patient care – meaning you spend all day at a treatment facility or stay at home.
The NHS often prescribes cognitive behavioural therapy (CBT) with a therapist that allows you to explore strategies to cope with AN. This will often be weekly and can be online or in person. As the therapy progresses, group therapy may also be offered to give you additional support. However, the NHS has a long waitlist as eating disorder incidence rises, meaning many individuals seek private treatment.
Private treatment (now increasingly being offered on commercial health insurance in the UK) tends to focus on a more rounded approach with therapy being used in conjunction with psychotherapists, nutritionists and dieticians, and physical therapists – as they tend to all be under one roof as it were. In the NHS this would require further referrals so one GP / therapist will be your main point of contact.
What is anorexia restricting subtype?
A person experiencing the restricting subtype of AN restricts their energy intake through dieting, fasting and / or exercise.
What is anorexia binge purge subtype?
A person experiencing the binge / purge subtype of AN experiences recurrent episodes of binge eating and / or purging behaviour. Overall food is still restricted, but binge eating episodes characterised by a lack of control occur. Purging can include the use of laxatives, diuretics, enemas or self-induced vomiting.
This is in the three months prior to diagnosis.
What are the warning signs of Anorexia Nervosa?
Some warning signs can include:
- Being ritualistic around food
- Strict rules around food
- Regular check ins of bodyweight, with an impact on mood based on the number
- Avoiding eating socially
- Social isolation
- Excessive or compulsive exercise with the intention of weight loss
- Obsessing over body size / shape through body checking, skin pinching, checking in mirrors etc.
- Intense anxiety around food, and eating
- Amenorrhea – absence of menstrual cycle, or delayed onset of first period
- Obsession with food – thinking about food
- Perfectionism and very high standards
- Constipation, bloating, physical weakness and lack of muscle strength
- Hormonal effects
In others this might look like someone:
- Saying they have eaten earlier / will eat later to avoiding eating with you
- Not being honest with you about their weight
- Hiding food from you
- Eating very slowly
- Being irritable, especially when talking about food or at meal times
- Excessively exercising or being anxious about missing exercise
- Wearing baggy clothing to hide their body
- Dropping out of social plans
- Withdrawing from education / employment
There are a number of warning signs of anorexia, but you don’t have to have all of them to be suffering. Even if one sign is present it may be useful to seek help to ensure others don’t occur, and stop anorexia from developing.
If left untreated AN can be fatal.
The SCOFF questionnaire is often used to determine quickly if you may be at risk – do two of the below apply to you?
- Do you ever make yourself Sick because you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you recently lost more than One stone in a three-month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?
What to do if you think you have Anorexia Nervosa
- Speak to a loved one. The more support you have the less of a burden you are carrying, and the sooner you can access further support. It can be tiring dealing with an eating disorder alone, confiding allows you to come to terms with your experience while sharing.
- Think about the type of support you might like. At Ease Nutrition therapy we offer specialised nutrition counselling support. You can get in touch with Shannon here.
If you are worried you or someone you know are suffering from AN seek out some support and potential treatment. The sooner you seek treatment the greater the chance of recovery, and the less alone you will feel.
We hope this blog was helpful to give you some clarity on Anorexia Nervosa.
Best wishes,
Team Ease Nutrition Therapy.