Anorexia Nervosa
Anorexia nervosa, commonly called anorexia, is an eating disorder characterized by an excessively low body weight. Officially, a person would be diagnosed with anorexia if he or she weighed 85 percent or less of what is considered normal for someone of the same age, sex, and height.
People with anorexia struggle with an intense fear of gaining weight and becoming what they consider to be fat. They often try to lose weight, or maintain a very low body weight, by restricting the amount of food they eat or by purging themselves of the food they’ve already eaten. Restriction is often accomplished with dieting and the use of diet pills, while purging is usually done through vomiting and/or the use of laxatives. Between 40 and 80 percent of people with anorexia also engage in excessive exercise to burn up the few calories they allow themselves to digest.
People with anorexia spend a great deal of time analyzing their looks in the mirror, and no matter how much weight they lose, they never think it’s enough. People with anorexia never think they look good enough, despite the excessive amount of time they spend focusing on the way they look and limiting the amount of food they digest. The inability to see the danger of their situation is part of the disorder.
Some people with anorexia also indulge in binge eating before they purge. Binge eating is an activity that takes place in the span of a few hours and usually involves consumption of a large quantity of high-calorie foods. For example, this could mean that a person eats multiple bags of candy and chips at home, or it could mean going to a number of different fast-food restaurants in a short period of time to eat multiple meals. Most often, this type of behavior is done in secret and alone. Many people binge because they feel stressed, anxious, depressed, or extremely hungry. During bingeing, some people feel that they’re out of control and can’t stop eating, while others report feeling like they’re outside of their bodies.
After eating such large quantities of high-calorie foods, people with anorexia feel guilty about what they’ve done and become fearful of gaining weight. So they force themselves to vomit to prevent the food from being digested. Purging can also be accomplished through the abuse of laxatives, diuretics, enemas, or syrup of ipecac. Other people with anorexia offset their binge eating by engaging in excessive exercise or by fasting for multiple days.
A person who regularly binges and purges but is of approximately normal weight might be diagnosed with bulimia, while a person who binges without purging, exercising, or fasting might be diagnosed as suffering from binge-eating disorder.
The excessively low body weight of a person with anorexia is dangerous because it causes a wide variety of health problems. In actuality, anorexia is self-induced starvation, and the resulting health problems are the same ones that would be seen in a person suffering from starvation caused by war, poverty, or famine.
Anorexia can lead to heart complications, such as an excessively slow heart rate, mitral valve prolapse, and congestive heart failure. Other related problems include osteoporosis, liver damage, anemia, stomach pain, constipation, hypoglycemia, a sensitivity to cold temperatures, brittle nails, small bruises on the arms and legs, thinning hair on the head, and the development of fine downy hair on other parts of the body.
The erosion of dental enamel is also common among people who purge after eating, due to the reflux of their stomach acids. More than 95 percent of adult women with anorexia also stop having their periods. However, many of these problems are reversible if anorexia is treated early in its course and the person regains a healthy weight. Unfortunately, despite these dangers many cases of anorexia last as long as ten to fifteen years.
Many people with anorexia also struggle with other mental health problems, such as depression, anxiety, and substance abuse. Because of these combined problems, it’s an unfortunate fact that the rate of suicide among people with anorexia is higher than that of the general population. Because of the serious health risks associated with anorexia, as well as its association with depression and suicide, anorexia is an illness that requires immediate and intensive treatment as soon as possible.
A study published in the medical journal Lancet in 2000 surveyed eighty-four patients twenty-one years after they’d been hospitalized for anorexia. While half of them had fully recovered, almost 16 percent had died from related complications, such as infection, dehydration, and suicide.
Sadly, this mortality rate is the norm, rather than the exception. In fact, for women between the ages of fifteen and twenty-four, anorexia leads to more than twelve times as many deaths each year than do all other causes, which by some estimates means that it kills more Americans each year than any other mental health problem.
Anorexia affects over one million Americans. In most reported cases, it appears to affect women more than men. Over the course of their lives, approximately 1 percent to 4 percent of all women will develop the illness. Overall, men report anorexia only one-tenth as often as women do, and research seems to indicate that men who identify themselves as gay or bisexual are often at a greater risk for developing anorexia than are heterosexual men. However, it’s believed that the general rate of anorexia for all men is higher than officially recognized, either because it goes undiagnosed by doctors or because men are ashamed of reporting it. In both men and women, anorexia usually develops between the ages of twelve and twenty-six, with the greatest frequency between the ages of fourteen and eighteen.
The exact causes of anorexia are still not fully understood. However, both psychological and social factors are believed to play a role. Some researchers think that anorexia is a form of restriction that certain people use in an attempt to control their lives and their bodies. Others see the disorder as an unsuccessful attempt to control or suppress unwanted emotions. One study also found that anorexic women thought of themselves as being less independent from their families than did their non-anorexic sisters.
One theory about the development of the disorder is that the Western idealization of beauty and thinness has led many women to become depressed and anorexic. There is even some research to suggest that the general messages seen on television and in magazines reinforce these ideas in women who already have anorexia.
However, anorexia is not confined to the Western world. Cases have also been recorded in places like sub-Saharan Africa, where anorexic female students limited their food consumption for self-imposed religious reasons, not because they wanted to be thin.
Treatment of anorexia usually requires a team of medical and psychological professionals. The immediate medical concern is to return the anorexic person to a healthy weight and to handle any related health problems. For some people, this may require hospitalization. In conjunction with this, intensive psychological treatment is also required. However, more research is still needed to find effective treatments for anorexia. Currently, there is no single psychotherapy that will be effective for every person struggling with the disorder. Therefore, a person looking for treatment may need to try more than one psychotherapy before the best match is found.
Adults struggling with anorexia have found some success using cognitive behavioral therapy. A small study published in 2003 in the American Journal of Psychiatry reported that adults who enrolled in cognitive behavioral therapy after hospitalization for anorexia had lower rates of relapse and better outcomes when compared with adults who only enrolled in supportive nutritional counseling.
Acceptance and commitment therapy, a form of behavioral therapy, was also reported to be successful in a single case study of anorexia. Family therapy has successfully been used to treat the disorder, especially when used to help children and adolescents. Overall, many forms of psychotherapy are thought to be helpful, especially if they offer support and include dietary advice.
Studies of medications suggest that antidepressants can be helpful for anorexics who also have symptoms of depression. However, when used as the sole means of treating anorexia, antidepressants won’t work for everyone.
Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. When used in conjunction with medical treatments for anorexia, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.
The CBT treatment for anorexia is often composed of seven steps:
- Conduct an assessment and provide education
- Address health and eating issues
- Get reactivated in life
- Challenge and correct self-defeating thoughts
- Increase self-esteem
- Develop emotion regulation skills
- Prevent relapse
Step 1: Conduct an Assessment and Provide Education
The first step of the CBT treatment for anorexia is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with anorexia and not some other similar problem, such as bulimia or binge-eating disorder. Once people are diagnosed with anorexia, it’s important that they and their family members understand the basic nature and causes of the disorder (as highlighted above), and that CBT is an interactive treatment that requires the person to do work outside of the therapy session.
Step 2: Address Health and Eating Issues
The primary concern while treating anorexia is the person’s very low body weight. As stated before, anorexia is self-induced starvation that brings with it all of the same emergency medical issues that affect those suffering from starvation due to war, poverty, or famine. Therefore, the most important issue is to increase the amount of food the person is eating and to ensure he or she retains that food by refraining from purging activities. This can be very difficult since eating and food trigger the person’s fears about gaining weight and losing control of life, emotions, and so on. Yet, eating food is exactly what the person must do three to five times a day to become healthy and successfully overcome the disorder.
At this stage of treatment, it’s often helpful and necessary to have the assistance of a medical and/or nutritional specialist. It’s vital that the person with anorexia understand the dangers of not eating, as well as the necessity of replenishing nutrients with food. Plus, depending on the severity of the disorder, the person might need medical supervision to treat related problems.
Depending on the severity of the person’s weight loss, this might be the only step in the treatment that can be successfully performed until sufficient weight is regained. Until that time when the person’s weight approaches a healthy range, he or she might not be able to function in any type of psychological treatment. A severe restriction of calories can cause cognitive and emotional problems that interfere with the person’s participation in treatment. Therefore, until caloric intake is increased and maintained, the person’s brain and body might not be able to do what is necessary to cope with the disorder.
If the person with anorexia also engages in binge eating and/or purging, it’s necessary to eliminate those behaviors at this stage of treatment. Again, this can be very difficult to accomplish, but the person’s very life might depend on eating without restricting his or her diet, and maintaining the calories without expelling them before digestion.
To develop healthier eating habits, the person with anorexia might also need help overcoming fears of “forbidden foods,” education about healthier foods, coping skills for dealing with cravings, and skills for avoiding binges.
Step 3: Get Reactivated in Life
Depending on the severity of the person’s anorexia, the next step of the CBT treatment for anorexia might be to help the person begin scheduling pleasurable activities back into his or her life. When people with anorexia become depressed, they often isolate themselves from the rest of the world and avoid fun and interesting activities, which, ironically, only serves to deepen their depression. One of the most important steps of treatment, therefore, might be to get people reactivated in life and help them stop avoiding pleasurable activities. This can be done in many ways, but using a schedule to plan and record activities is often helpful and motivating.
Step 4: Challenge and Correct Self-Defeating Thoughts
After the person with anorexia has gained enough weight that he or she is out of the danger zone of starvation and the person’s brain and body are once again getting enough nutrients to function properly, psychological treatment can proceed.
The core of the CBT treatment for anorexia is to challenge and correct negative thoughts about self-image, food, and weight. These thoughts are often the cause of anxious, sad, and hopeless feelings. At the most observable level are automatic thoughts. These are critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “I’m too fat” and “If I were thinner, my life would be better.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels anxious, sad, or hopeless.
Much of the CBT treatment for anorexia will be spent identifying and reevaluating these types of thoughts. This can be done with the use of a thought record. People with anorexia often struggle with distressing thoughts about food, weight, and their self-esteem. The thought record helps them look for evidence that both supports and contradicts these thoughts. Then, most importantly, it helps them create a more balanced thought. For example, if the person struggling with anorexia had the thought “I’m too fat,” the thought record would offer evidence of this thought being true and examples of it not being true in his or her life.
The thought record also helps the person identify different types of cognitive distortions, or unhelpful thinking styles. People with anorexia often have rigid, unrealistic standards that they use to measure their self-worth. Unhelpful thinking styles often support these unhealthy standards and therefore must be challenged and reevaluated, too. For example, a woman who catastrophizes thinks that her life will be a complete failure unless she’s the perfect weight, while a man who uses “shoulds” and “musts” believes that he should always eat the smallest amount of food because he must not have any fat on his body.
By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find new, healthier thoughts and ease feelings of anxiety, sadness, and hopelessness. In this example, perhaps a more balanced thought would be “Even though I often think I’m too fat, there’s actually a lot of evidence that I’m not.” And instead of feeling excessively anxious, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less anxious, say only a 5 out of 10.
As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to anorexia. These core beliefs, often called schemas, include thoughts like “I’m defective,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques.
Step 5: Increase Self-Esteem
Self-esteem is the value people put on themselves, based on both facts and the opinions of themselves and others. Unfortunately, people with anorexia often have very low self-esteem because they usually focus on negative, self-defeating evaluations and disregard positive evaluations. Luckily, there are many skills and techniques that help increase self-esteem. These skills include being mindful of the labels used to describe oneself, challenging self-critical thoughts, developing self-compassion, making a more accurate self-assessment, avoiding the “shoulds,” reframing past mistakes, using assertive communication skills, and practicing visualization.
Step 6: Develop Emotion Regulation Skills
Emotion regulation skills serve a number of different purposes. They help people identify their emotions more clearly and easily, and help them cope with painful emotions instead of getting overwhelmed by them. People with anorexia often try to control or avoid undesirable emotions, like anger, frustration, and sadness. Part of the CBT treatment for anorexia involves developing an acceptance of these feelings and learning how to express them in appropriate ways. Emotion regulation skills also help people reduce their vulnerability to overwhelming emotions, increase their experiences of positive emotions, and learn to be mindful of emotions without judging them. Skills such as emotion exposure techniques can help people learn not to fear their feelings. Learning to do the opposite of emotional urges blocks ineffective, emotion-driven responses to situations. And, finally, problem-solving skills can help a person develop coping strategies for events that trigger difficult emotions.
This stage of treatment might also include the development of interpersonal effectiveness skills. These skills can help people with anorexia learn how to express their thoughts and feelings in effective ways that help them get their needs met. Mindful attention skills are useful for recognizing how others are feeling and creating more satisfying relationships. Assertive communication and listening skills are also powerful interpersonal tools. These skills can help people get their needs met, set limits with others, learn how to say no, and negotiate for what they want.
Step 7: Prevent Relapse
Finally, the last step of the CBT treatment for anorexia is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning anorexia in order to take steps to prevent relapse.
Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.
ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.
The ACT treatment for anorexia generally includes eight steps:
- Educate about anorexia and ACT
- Develop creative hopelessness
- Focus on contact with the present moment
- Utilize cognitive defusion
- Develop acceptance
- Clarify values
- Commit to taking action
- Stay committed to values and actions
Step 1: Educate About Anorexia Nervosa and ACT
The initial step of the ACT treatment for anorexia is education. It’s important to educate the person and the person’s family members about anorexia and the nature of emotions like anxiety and sadness. It’s especially important for the person with anorexia to understand the nature of these things from an ACT point of view. According to this treatment, food, weight, anxiety, and sadness are not the causes of anorexia. Rather, it’s the person’s attempts to avoid and control certain emotions and thoughts that make anorexia an overwhelming problem. Starting with the early stages of treatment, it’s also important for everyone involved to understand that ACT is an active, participatory treatment designed to help him or her live a more fulfilling life, not necessarily a “happier” one.
Step 2: Develop Creative Hopelessness
In order to develop what ACT calls “creative hopelessness,” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with anxiety and sadness. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of anxiety and sadness, which can never be successful. For example, a woman who attempts to control her anxiety about her weight by further restricting how much she eats actually develops a worse problem, as does a man who tries to avoid his sad feelings about his food choices by purging after he has eaten. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with anxiety and sadness.
Step 3: Focus on Contact with the Present Moment
Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling anxiety and sadness. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body.
Step 4: Utilize Cognitive Defusion
Cognitive defusion is a mindfulness technique that helps people observe their anxious and fearful thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with anorexia to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that anorexia could worsen over time if a person were to follow or believe every thought and emotion that arose.
Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings.
Step 5: Develop Acceptance
In ACT, learning to accept frustrating situations and distressing emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.
In order to cultivate acceptance, people are encouraged to experience the distressing emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded.
Step 6: Clarify Values
ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. Clarifying and establishing what a person values can often help that person live a more fulfilling life, despite having occasional feelings of anxiety or sadness. Values are the elements of life that give it meaning and importance, like “maintaining relationships with my friends” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a relationship and still have a caring relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values.
Step 7: Commit to Taking Action
After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a woman’s value is to reconnect with her friends, she might list a number of different goals to fulfill that value, such as “call them twice a week” and “schedule more activities with them.” These are goals that can be completed and thereby create a sense of valued living. The ACT treatment for anorexia includes development of skills and goals that lead to taking committed action.
Step 8: Stay Committed to Values and Actions
Finally, in order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past.
Disclaimer
This website is for informational purposes only and does not provide an official diagnosis. Anyone struggling with a physical or mental health problem should seek the services of a medical or psychological professional as soon as possible. Furthermore, if you’re having thoughts about suicide or hurting someone else, please see our crisis resources list, contact your local emergency services, or go to a local hospital immediately.
