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What is Anorexia Nervosa?

Anorexia nervosa is an eating disorder, especially common in – but by no means confined solely to – women. The disorder usually begins in adolescence or early adulthood, the mean age of onset being 15 years, but can start at any point between 6 and 72 years. If it does occur later in life it is more likely to be associated with severe psychological or physical disease (see Chapter 4). The central physical feature of AN is an abnormally low body weight, 15 per cent below that recommended for the age, height and sex of the person, accompanied by amenorrhea (the cessation of menstrual periods) in girls.

There are many physical and psychological symptoms secondary to starvation, but AN is principally a psychological disorder. Its characteristic feature is a fear of fatness, indeed fear even of existing at a normal body weight. This is accompanied by an intense pursuit of thinness. There is also nearly always a distortion of body image in which individuals perceive themselves as fat or overweight even when everyone else thinks they are grossly underweight. Other methods apart from starvation may be employed to maintain low weight, such as exercising, vomiting or purging.

Although clinical studies have shown AN to be more prevalent in higher social classes, population studies show equal distri bution in all social groups, which suggests that there is a degree of under-diagnosis and under-treatment of socially disadvantaged people with eating disorders.

In some cases, what begins as a harmless diet escalates. Success brings with it feelings of achievement and control. Often, individuals vulnerable to AN are in circumstances where they feel trapped and under pressure to succeed; or they feel out of control in their lives. The reward they get from exerting control over their food intake and consequent weight becomes of exaggerated importance and may begin to dominate their existence. Chapter 5 sets out some of the factors which make particular individuals vulnerable to developing AN.

AN is one of a group of eating disorders particularly prevalent in adolescent girls. Also in this group are bulimia nervosa (BN) and binge-eating disorder. BN is characterized by constant dieting punctuated by episodes of loss of control. These binges may be very large, involving many thousands of calories, and are followed by purging, either with self-induced vomiting or laxative abuse, or a combination of the two. People with BN are usually within the normal weight range. Individuals with binge-eating disorder have episodes similar to those with BN but they do not purge. They may have periods of marked starvation between their binges. People with this disorder are generally in the normal or obese weight range. These eating disorders may exist independently and exclusively, but a person may have different variants at different times.

Approximately 0.5 per cent of the female population suffers from AN, 2 per cent from BN and a further 2 per cent from binge-eating disorder. If we include partial syndromes, which may represent those in the early stages of the disorder or those who are partially recovered, these figures can be doubled; that is, some version of these disorders affects approximately 10 per cent of girls and women. The sex ratio for AN is 10:1 female:male (no corresponding figure for BN has yet been established). AN also carries a substantial risk of fatal outcome: follow-up studies of severe hospitalized cases of AN show that between 0.5 and 1 per cent of these individuals will die of causes related to the disorder, two-thirds from the physical effects of starvation and a third from suicide.

These figures may be disturbing, even frightening; but it is important to remember that:

•   Eating disorders are common: you are not alone or unique. On the contrary, many others share your problem.

•   In order to prepare yourself for treatment, it is good to learn as much as you can about the disorder of AN and how it can be treated.

Some common myths about AN

Misguided, distorted and just plain wrong ideas about AN abound. Some of the most common are worth examining and refuting at the outset, because only with an accurate picture of the disorder can it be effectively tackled.

Myth: AN only occurs in women, particularly young women.

Reality: It occurs in men of all ages and in women of all ages.

Myth: AN is a disorder of privilege, occurring mainly in the upper and middle social classes.

Reality: Clinic attendees tend to be from higher social classes, but it occurs across all social back grounds and all levels of affluence.

Myth: Pressure or influence by the media causes AN.

Reality: This is too simple an explanation. AN has multiple causes. AN is not simply trying to be thin to be more attractive.

Myth: AN is caused by families, by certain patterns of family interaction and by mothers in particular.

Reality: This view, which is widely held, causes parents and daughters alike a great deal of distress and guilt. Most of the problems in families where a member has AN are a result of the disorder rather than the cause of it.

Myth: AN is caused by simple dieting which gets out of control.

Reality: On its own, dieting does not cause AN. The majority of women have dieted at some time, and many have done so frequently. Only a minority get AN.

Myth: AN is not a serious disorder.

Reality: It clearly is. In many cases it is very difficult to treat. The physical complications are severe and the death rate among the most seriously affected is high.

Myth: Once you have AN you will never recover – you will always be ‘an anorexic’.

Reality: This is not true. Follow-up studies show that recovery is possible even after as much as 12 years of continuous severe symptoms.

How to distinguish between AN and dieting

AN is not caused by dieting. However, AN and dieting clearly do have certain things in common:

•   Weight loss is the goal.

•   To achieve weight loss, food intake is reduced.

•   Exercise may be combined with a reduced food intake to increase, or speed up, weight loss.

•   Calorie values are learnt and computed, sometimes quite obsessively, to the extent that the dieter/person with AN can remember the calorific values of all the foodstuffs she eats regularly without consulting a calorie guide.

However, despite these surface similarities, the differences are many and substantial.

Someone on a diet, as opposed to someone with AN, will generally:

•   admit to being a dieter, and often be keen to discuss the diet, target weight, feelings of deprivation, lapses and triumphs;

•   admit to feelings of deprivation and to having cravings for specific foods;

•   feel a sense of satisfaction from achieving an ideal weight, and be content to reach that level and not lose any more weight;

•   experience an increased interest in food, but try to steer clear of situations involving food so as to avoid temptation;

•   not be competitive with family members in terms of reduced food intake, i.e. not feel defeated if she finds that she has eaten more than another member of the family;

•   put their diet ‘on hold’ for special occasions that involve eating, such as a birthday meal or a Christmas dinner;

•   whether frequently or rarely, bend the rules of the regime, and not be unduly disturbed in so doing;

•   not be very consistent: weight loss from dieting is usually uneven with a dieter losing one pound one week and three the next, or even regaining lost weight through excessive rule-bending;

•   often fail: most diets are given up quickly and lost weight is regained;

•   work to a schedule: diets are generally time-specific, especially fad diets that promise a certain weight loss within a certain time-frame e.g. ‘Thin Thighs In Ten Days’, or regimes embarked upon with a particular end-date in mind, such as the departure date for a foreign holiday;

•   have a reasonable goal – at least in terms of projected weight loss, if not always in terms of projected time taken to achieve it: thus some diets seem spectacularly effective at the time, but much of the lost weight will be fluid, not fat, and therefore quickly replaced;

•   eat quickly in an attempt to satisfy hunger;

•   avoid people who are eating indulgently, or even normally, as this enhances their feelings of deprivation;

•   seek the support of others in their attempt to lose weight.

By contrast, the person with AN will generally:

•   often deny being on a weight-loss diet;

•   not admit to feelings of deprivation, or to craving specific foods, particularly of the high-calorie variety;

•   tend to deny weight loss, and even attempt to hide it by wearing baggy, figure-concealing clothes;

•   not seem to become distressed by the close proximity of food, but rather actually to enjoy it: many people with anorexia develop a great interest in cookery and preparing food for other people;

•   strive to eat less than those around him or her: in the case of female anorexics, eating less than the mother and/or sister(s) is particularly important;

•   tend to dish out unreasonably large helpings to other people at mealtimes; this may relate to the desire to eat less than others;

•   be wholly dominated by the desire to be thin and the morbid fear of becoming fat;

•   continually revise target weight downwards;

•   tend to become obsessed with food–like the dieter– but, rather than trying to avoid things associated with food will seek them out, for instance by studying cookery books, visiting supermarkets and cooking;

•   linger over food, chewing slowly and thoroughly, and trying to ensure that she finishes eating after everyone else;

•   tend to become increasingly phobic about eating in public, and may hoard food in order to eat alone and unobserved;

•   see a distorted image, feeling fatter while getting thinner, and become increasingly sensitive and plagued by feelings of low self-worth;

•   link self-esteem inextricably with perceived body size and weight;

•   never break the rules – or actively fear doing so, and become deeply distressed if she does, whereas a dieter may treat herself to the odd indulgence and at worst be annoyed afterwards;

•   tend to become very competitive and obsessional about achieving: exactness about mealtimes, calorie content of foods and eating rituals is mirrored by increasing obsessionality in other areas of life such as schoolwork and relationships.

How common is AN?

The short answer is: Very common. Eating disorders appear to be occurring more and more often in Western countries, with severe conditions such as BN and AN affecting two or three teenagers in every 100 and reaching a peak of one in 100 among those between the ages of 16 and 18.

Unfortunately, some of those affected by AN do die as a result, most commonly from late-diagnosed infection, hypothermia, irreversible hypoglycaemia or suicide, rather than from the direct results of malnutrition.