Anorexia Nervosa is a complex disorder manifested by physiological, behavioral, and psychological changes and characterized by morbid fear of fatness, gross distortion of body image, and unrelenting pursuit of thinness. The name is actually a misnomer, since true anorexia (loss of appetite) does not usually occur until late in its course. Although it typically begins in adolescence, the range of onset is between 10 and 30 years.
Symptoms & Signs
Individuals with anorexia nervosa go to incredible extremes to lose weight. They begin by drastically reducing caloric intake, with virtually complete avoidance of high-carbohydrate and fat-containing foods. They exercise incessantly - walking, running, swimming, cycling, dancing, and performing calisthenics. Hyperactivity is dramatic and persists even when weight loss has resulted in cachexia. Some patients alternate fasting with bulimia - episodes of uncontrolled gorging without awareness of hunger or satiation. Such eating binges are often followed by self-induced vomiting. Huge quantities of laxatives are commonly consumed. Diet pills and diuretics may also be abused in the effort to lose weight. There are two types of anorexia nervosa: Patients who engage in binge eating and purging behavior are diagnosed as having the binge eating/purging type and patients who simply starve themselves are diagnosed as having the restricting type.
The eating behaviors of anorexics are often peculiar and may be bizarre. The diet may be exceedingly monotonous or highly eccentric. Large quantities of food may be hoarded or small amounts of food may be hidden around the house. Although they eat very little, anorexics are obsessively preoccupied with food and cooking. Food portions are carefully measured, and small meals may be eaten over many hours. Food is often stored, prepared, served, eaten, and disposed of in a specific, ritualistic fashion. Patients with anorexia nervosa are usually highly secretive and often lie to protect the privacy of their eating behaviors. Kleptomania and stealing are sometimes associated with this disorder, particularly among individuals who also have episodes of bulimia.
Although these features of anorexia nervosa can occur in individuals with a variety of premorbid personality structures and traits, a fairly consistent profile of emotional and psychological manifestations common to all patients with this disorder has been described. Clinicians generally agree that the unrelenting pursuit of thinness manifests an underlying psychological struggle to maintain a sense of personal autonomy and self-control. On the surface, patients are stubbornly defiant and fiercely independent. They insist they are happy, fully aware of their condition, and completely capable of taking care of themselves. But underneath they are stricken with a paralyzing sense of helplessness and ineffectiveness, with control over eating and body size the only mechanisms through which a sense of autonomy and mastery can be sustained. This important insight into the psychology of anorexia nervosa was discovered in 1962 by Hilde Bruch, who also described two other essential features of this disorder: a characteristic misperception of internal body cues, so that patients are unable to differentiate their own feelings and needs from those of others; and a disturbance of body image, so that patients see themselves as grotesquely fat even when exceedingly thin. These cognitive and perceptual distortions accentuate the sense of personal ineffectiveness and reinforce the need to continue the pursuit of thinness to maintain a sense of control.
The lack of confidence in basic self-control is compounded by feelings of personal mistrust. Patients fear they will give in to overwhelming impulses and, so far as eating is concerned, gorge themselves into obesity. Individuals with anorexia nervosa also tend to view themselves in terms of absolutes and polar opposites. Behavior is either all good or all bad; a decision is either completely right or completely wrong; and a person is either absolutely in control or totally out of control. Thus, the gain of an ounce may produce the same sense of horror as would the gain of 100 pounds. Self-mistrust and the tendency to view the world in absolutes reinforce the exaggerated need to maintain rigid control over what is and is not eaten.
Patients with anorexia nervosa often express fear about becoming adults, since that would mean either tolerating intense loneliness or entering the world of interpersonal and sexual relationships. Although desperate for contact, they are mistrustful of relationships. They are often frightened of sexuality and usually avoid sexual encounters. When they do engage in sexual activity, it is usually without enjoyment.
Low self-esteem is invariably present, with the ability to lose weight being the only thing many patients like about themselves. Patients with anorexia nervosa describe intense feelings of inner shame about their bodies in general, with their fat content a specific object of disgust.
Revision date: June 22, 2011
Last revised: by Jorge P. Ribeiro, MD