Anorexia
What Is It?
Anorexia is an Eating Disorder that usually begins during adolescence/early adulthood, with an increasingly earlier onset. The core features of Anorexia include voluntary and intentional refusal to maintain a healthy body weight for age and height, intense fear of gaining weight, and a distorted body image with disturbances in the perception of one's weight and shape.
What Types Exist?
Since different forms of this condition may overlap during the course of Anorexia, the following types are used to characterize current symptoms rather than the disorder itself.
Binge-Eating/Purging Type: Characterized by episodes of binge eating and bulimic or purging behaviors through voluntary vomiting or the use of laxatives, enemas, or diuretics. Some individuals with this type of Anorexia may not experience binge-eating episodes but engage in purging behaviors even after consuming small amounts of food.
Restrictive Type: Characterized by severe and persistent food intake restriction and the absence of binge-eating and purging behaviors.
What Are the Main Signs and Symptoms?
The diagnosis of Anorexia is complex due to its proximity to other eating disorders. Therefore, it is essential to consult a specialized professional, such as a psychologist, to ensure a comprehensive and reliable clinical diagnosis. However, it's important to be aware of the main signs and symptoms, which can manifest in different domains:
1) Behavioral and Cognitive Domain:
- Maintaining a restricted (calorically) and deficient (nutrient-wise) diet, regardless of the level of leanness;
- Obsessive thoughts and compulsive behaviors related to food and dietary characteristics (e.g., continuous research on new diets, refusal to eat in public spaces, rigorous and persistent measurement of food portions to be consumed);
- Pretending to eat or lying about eating behaviors;
- Feeling and describing oneself as fat regardless of having a weight well below healthy standards for age and height;
- Obsessive thoughts and compulsive behaviors related to body image (e.g., weighing oneself multiple times a day, persistent concerns about minor fluctuations in body weight);
- Exaggerated self-criticism about body image - persistent perception of not being thin enough.
2) Emotional Domain:
- Low self-esteem;
- Self-blame;
- Self-criticism.
What Are the Possible Causes and Risk Factors?
Anorexia is a complex disorder with multifactorial origins, involving biological, psychological, intrafamilial, environmental, and sociocultural variables. While these factors are not determinants of the disorder, they play a significant role in its development and serve as predictive factors. Psychological and environmental risk factors are highlighted:
Psychological Factors
- Low self-esteem associated with high interpersonal sensitivity;
- High perfectionism, with food restriction emerging as an attempt to regain a sense of self-control.
Environmental Factors
- Physical and/or sexual abuse (in these cases, the fragile and unattractive self-image emerges as an avoidance of anticipated abuse);
- Conflicts in romantic/intimate relationships;
- In cases of adolescent-onset Anorexia, parental separation or divorce can be a significant risk factor;
- Significant life changes such as leaving home and/or entering college in the case of adolescents.
Can It Be Associated with Other Disorders?
Psychological Disorders: Around 85% of patients with Anorexia have Depressive Disorder. There is a higher likelihood of developing this psychopathology when there is a history of childhood sexual, psychological, or physical abuse. Anxiety Disorders tend to also occur in conjunction with Anorexia.
Physiological Disorders: Several physiological symptoms arise either in association with or as a consequence of Anorexia, as illustrated in the image below.
What Is the Prevalence and Mortality?
The prevalence of Anorexia has gradually increased in recent decades in several countries. This disorder is particularly widespread in Western societies, where the ideal of thinness is typically associated with high standards. There is also an increase in prevalence in non-Western societies, which tends to follow their development.
It is estimated that about 2,500 new cases are diagnosed annually worldwide, with an international prevalence of 0.5% to 1%. In Portugal, the prevalence ranges from 0.3% to 0.6%, with more than 90% of cases diagnosed in women. Genetically, it is estimated that 6 to 10% of female first-degree relatives of people with Anorexia also have this condition.
Anorexia has the highest mortality rate of all psychopathologies, ranging from 5% to 18%. In most cases, the cause of death is suicide, electrolyte imbalances, starvation (leading to frequent and repeated infections), cardiovascular, gastrointestinal, and endocrine diseases.
How Can Psychotherapy Help?
Anorexia requires a multidisciplinary approach that includes Psychology, Psychiatry, and Nutrition. Additionally, family and friends play a fundamental role in the recovery process, and their active involvement is important. In psychotherapy, an initial assessment is conducted to perform a differential diagnosis, ruling out other possible disorders. This information allows the psychologist to develop a personalized treatment plan, which may also be determined by the patient's individual characteristics, such as family history and personality profile. The goals of psychotherapeutic intervention aim at psychosocial stabilization, addressing various areas:
- Modifying restrictive and/or purging behaviors through psychoeducation;
- Changing erroneous beliefs and fallacious thoughts;
- Mood regulation and management of maladaptive emotional responses;
- Developing impulse regulation skills;
- Restructuring the relationship with food and body image.
If you have symptoms of Anorexia, it is important to seek help as soon as possible. Statistical data show that early intervention, at the onset of symptoms, is the most protective factor in reducing the risk of mortality.
Recommended Resources
Bryant-Waugh, R. (2002). Eating Disorders: A Parent's Guide. Editorial Presença: Lisbon.
Carmo, I. (1994). Life by a Thread - Anorexia Nervosa. Relógio d'Água: Lisbon.
Carmo, I. (2003). Why Can't I Stop Eating?. Dom Quixote: Lisbon.
http://www.anad.org/ [in English] National Association of Anorexia Nervosa and Associated Disorders
http://www.nationaleatingdisorders.org/ [in English] National Eating Disorders
References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association.
Dixe, M. A. (2007). Prevalence of Eating Disorders. Análise Psicológica, 4 (XXV).
Graves, Bonnie B. (2000). Anorexia. Capstone Press: Minnesota.
Leal, I. & Nodin, N. (2005). Paternal Representations in Anorexia Nervosa. Análise Psicológica, 2 (XXIII).
Van Eeden AE, van Hoeken D, Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. 2021 Nov 1;34(6):515-524.