*** Disclaimer: The following article includes information derived from our clinical team’s impressions as specialized professionals working directly with Eating Disorders in Windsor/Essex County.
Anorexia Nervosa is a complex eating disorder that is often misunderstood by the general public. Some are “fearful” of Anorexia due to the emaciated appearance of many of these individuals, while others brush it off, believing the resolution to be as simple as “just eating”. However, anorexia is not a choice – rather, it is a disorder that is linked to maladaptive compulsions and thought patterns. And although individuals who are underweight have been criticized for their startling appearance, they are not to be feared – they are worthy and capable people who find themselves stuck in a powerful and overwhelming eating disorder cycle.
It is important to remember that Anorexia Nervosa is a psychiatric disorder that is often further impaired by physiological outcomes of low weight. Due to lack of proper nourishment, individuals with this diagnosis often do not present as themselves, as they get “stuck” in the disorder and become preoccupied by their fears of food and “fatness”. Many of their thoughts and behaviours are much more characteristic of the disorder than they are of the individual’s personality. We stress that those supporting someone who struggles with Anorexia Nervosa do their best to educate themselves about the disorder and its symptoms, practice patience and their own self-care, and regularly remind themselves that the disorder is not who their loved one is; rather, it is a condition from which their loved one suffers from.
In the 2018-2019 year, we collected data on our active clients to determine how frequent each eating disorder diagnosis is at BANA. Because Anorexia Nervosa is one of the more “famous” eating disorders, it is often assumed that it is the most frequent. However, our findings indicate that it is somewhat rare, at a rate of 7.7% within our client population.
The 5th rendition of the Diagnostic Statistical Manual (DSM-5) is the current guideline used in North America to diagnose all mental health disorders. It outlines the requirements that must be met in order to receive any diagnosis within its pages.
DSM-5 CRITERIA FOR ANOREXIA NERVOSA
a) Restriction of energy intake relative to requirements, leading to significantly low body weight (defined as “less than minimally normal”) in the context of age, sex, developmental trajectory, and physical health
b) Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even if at a significantly low weight
c) Disturbance in the way in which one’s body weight or shape is experienced; undue influence of body weight or shape on self-evaluation; or persistent lack of recognition of the seriousness of the current low body weight
Subtypes: based on the symptoms involved in achieving and maintaining low weight
Restricting Subtype (AN-R):
- Presentations in which weight loss is accomplished through dieting, fasting, and/or excessive-exercise
- The individual has not engaged in binge-eating or purging behaviours within the last 3 months
Binge-Eating/Purging Subtype (AN-BP):
- During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (self-induced vomiting, the misuse of laxatives, diuretics or enemas)
Severity Ratings: based on the client’s current body mass index (BMI)
Mild = BMI of 17 or above
Moderate = BMI of or between 16-16.99
Severe = BMI of or between 15-15.99
Extreme = BMI below 15
“ABNORMAL” EATING BEHAVIOURS
Often eating disorders are accompanied by “abnormal” eating behaviours (sometimes referred to as “mealtime behaviours”); these abnormal behaviours are most frequently seen in individuals who have been diagnosed with Anorexia Nervosa. Although these behaviours are still not well understood by the research community, some evidence suggests that they are the result of anxiety around food and eating, as well as caloric intake. It has also been argued that some of these behaviours are a method of avoidance, and may serve as “rituals” in order to escape uncomfortable or distressing feelings when faced with mealtime. At BANA, we have heard clients describe their reasoning behind some of their abnormal eating behaviours; one example is dicing food into tiny pieces allows the individual to feel as though they are eating more than they are, and have a sense of control over their intake.
Here are some examples of “abnormal” eating behaviours:
- Dicing/cutting food into small pieces
- Inappropriate use of utensils (or no utensils)
- Only using certain utensils or dishes
- Using smaller plates or bowls to make portions appear larger
- Measuring or weighing food
- Calorie counting
- Nibbling/picking/taking small bites only
- Tearing or dissecting food
- Inspecting food in-depth/staring at food
- Arranging food in a particular way
- Chewing food and then spitting it out
- Taking long periods of time to eat small portions/slow eating
- Only eating within a certain time window; if this window is missed, the individual does not eat
EFFECTS ON PHYSICAL HEALTH
Out of all mental health disorders – not just eating disorders – Anorexia Nervosa has the highest rate of mortality. It is believed that the effects on physical health, such as starvation of the body and brain, is the reason why Anorexia Nervosa can be the most life-threatening mental health diagnosis.
Refeeding syndrome is a condition in which the individual’s body experiences a severe shift in electrolytes and fluid as a response to suddenly increased intake. When an individual with Anorexia has lost a significant amount of weight and does not maintain proper nutrition, their body can shift into a “catabolic” state, where it attains energy by breaking down body tissues (whereas a nourished body may reflect an “anabolic” state, where the body builds and repairs tissue). A catabolic state has been shown to decrease the muscle-mass of the heart, causing one’s heart to be smaller and more strained. When this individual is refed, but this refeeding is not carefully planned and medically monitored, there can be a cardiovascular collapse and/or cardiac arrhythmias caused by: a sudden change in metabolism: a significant shift in electrolytes; and an increase in blood volume that the smaller-heart cannot handle.
When refeeding syndrome occurs, the individual is at significant risk of death; this is one of the more common causes of mortality within this population. Appropriate weight gain can allow the heart to return to a normal size; however, it is recommended that weight regain and refeeding is done alongside medical professionals. It is for this reason that many individuals with anorexia nervosa are referred to inpatient/medical treatment centers, as most outpatient settings are unable to support the level of care needed to prevent refeeding syndrome.
Weight loss can also affect the heart in other ways, such as a slowed heart rate and blood pressure, and irregular heart rhythms that may cause sudden death. Pericarditis can also occur, which is a condition where fluid accumulates in the sac surrounding the heart.
Anorexia Nervosa has also been shown to damage the endocrine, gastrointestinal and pulmonary systems, with consequences such as:
- Infertility, or the loss of menstrual periods
- Dangerously low blood sugars and electrolytes
- Decreased production of both white and red blood cells
- Slowed metabolism
- Delayed gastric emptying
- Slowed GI muscles, resulting in constipation or diarrhea
- Impaired kidney function from dehydration
- Overall muscle deterioration
- Difficulty producing and maintaining body heat which can cause lanugo (the development of fine body hair)
- Dried and discoloured skin
- Hair loss
- Bone loss/osteopenia/osteoporosis
Another health consequence we often see with individuals who have Anorexia Nervosa and a lower BMI is cognitive impairment. Cerebral atrophy – or the shrinking of the brain – can occur, which can impair an individual’s ability to think rationally, and make sound judgments and decisions. Cerebral atrophy can also cause peripheral neuropathy – where one experiences weakness, numbness and pain throughout the body as a result of damage to the nerves and disruption to the brain’s communication with the body.
BINGING, PURGING & BULIMIA NERVOSA
One of the subtypes of Anorexia Nervosa is the binge/purge subtype. Individuals with this subtype of Anorexia share many of the same symptoms as individuals who have a diagnosis of Bulimia Nervosa. One common misconception is that binging and purging causes weight gain, and is only typical of individuals who are average or above-average weight; however, even individuals of a low weight may engage in these behaviours.
The DSM-5 notes under their “differential diagnosis” section that the main difference between these two diagnoses is weight; if an individual is experiencing these symptoms but does not struggle to maintain a “normal weight”, they may be diagnosed with Bulimia. Low-weight is typically seen as a BMI of below 19, but clinical impressions and the severity of symptoms may have some sway, and exceptions can be made if justified. Keep in mind that some individuals who are not of low-weight may struggle with Anorexia Nervosa, and that diagnostic categories of eating disorders are quite fluid.
Binge-eating and purging behaviours are often misunderstood, both in Anorexia and Bulimia Nervosa. There is a lot of confusion regarding what constitutes a binge, or what purging behaviours look like. For more information and discussion on these symptoms, please visit our article on Bulimia Nervosa, at:
Contrary to popular beliefs, Anorexia Nervosa affects individuals of all ages – often, it is assumed that this diagnosis only exists with adolescents. Furthermore, Anorexia Nervosa affects individuals of all genders, not just females (as the popular media tends to depict). It is also often presumed that recovery from Anorexia Nervosa is not possible; however, this is not the case. Although it is very normal that some individuals with Anorexia Nervosa require numerous levels of care and may need to pass through treatment programs multiple times before achieving remission, it is still very possible for individuals to recover from this disorder.
Anorexia Nervosa is very often misunderstood, and many individuals may find it difficult to identify symptoms. If any of the criteria outlined in this article hit-home, but you’re not sure if they meet all the requirements for a diagnosis, do not hesitate to contact us through general intake. We can meet with you to discuss potential symptoms, and can support you through some of your concerns.
Our general intake number is: 1-855-969-5530
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Centre for Clinical Interventions. (2018). What are eating disorders. Retrieved from https://www.cci.health.wa.gov.au/
Gianini, L., Liu, Y., Wang, Y., Attia, E., Walsh, B. T., & Steinglass, J. (2015). Abnormal eating behavior in video-recorded meals in anorexia nervosa. Eating behaviors, 19, 28-32.
Hamilton, G., & Elenback, R. (2018). Anorexia nervosa – highest mortality rate of any mental disorder: Why? Retrieved from https://www.eatingdisorderhope.com/information/anorexia/anorexia-death-rate
National Eating Disorders Association. (2018). Anorexia nervosa. Retrieved from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia
National Eating Disorders Association. (2019). Eating Disorder Myths. Retrieved from https://www.nationaleatingdisorders.org/toolkit/parent-toolkit/eating-disorder-myths
The Recovery Village. (2020). 8 common myths about anorexia. Retrieved from https://www.therecoveryvillage.com/mental-health/anorexia/related/anorexia-myths/#gref