Anorexia
What is anorexia nervosa?
Anorexia nervosa is a serious mental illness that pervades all aspects of an individual’s life and has profound physical and psychological effects on them, and on those around them. The illness is much more common in young women, though recent studies have identified much higher rates of anorexia in men than previously thought. Anorexia is a highly visible disorder and evokes intense emotional response from others, particularly from those closest to the individual who is ill.
People with anorexia nervosa deliberately keep themselves at a weight far below that considered to be healthy for their height and age by restricting their food intake. Some individuals also exercise excessively or ‘purge’ after eating to control their weight even further.
People with anorexia feel fat even when they look emaciated. They have an intense fear of gaining weight despite being drastically underweight: losing weight or maintaining an abnormally low weight becomes a way of life and they will take extreme measures to avoid increasing their weight. They minimise or deny the seriousness of low body weight and the effects of starvation. They have distorted thinking patterns, and feelings of being defective and worthless – this affects not only their eating, but all parts of their life, including relationships, family life, work and leisure.
People with anorexia don’t ‘just grow out of it’. When the illness takes hold, they are often in such a deep state of denial about the amount of weight loss and its physical and psychological consequences, and are so afraid of gaining even the smallest amount of weight, that they are terrified of seeking treatment. They value their undernourished state and are reluctant to contemplate change. However, left untreated, anorexia can continue to dominate the life of an individual indefinitely, and in around 10 to 20 per cent of cases, it is fatal. There is also a relatively high rate of suicide among people with anorexia.
What are the symptoms of anorexia?
There are two types of anorexics: the restricting type, where an individual maintains a low body weight purely by restricting food intake and sometimes through increased physical activity; and the binge-eating/purging type, where food intake is restricted but the individual also regularly engages in binge eating and or purging, including self-induced vomiting and misuse of laxatives, diuretics or enemas. In the first type, the main method of weight loss is through self-starvation.
Anorexia generally starts with mild dieting, causing no concern. Often an individual is given compliments about their slimmer figure: weight loss is then seen as a positive achievement. Soon, an intense fear of gaining weight and an obsessive interest in what others are eating develops. An individual will spend hours watching cookery television programmes, trawling through recipe books, cooking elaborate meals for others, examining packages in supermarkets, studying menus, calorie checking and counting, and continually turning the topic of conversation to food, restaurants, flavour and diets.
Family and friends may not at first realise that someone is eating tiny amounts – the individual will give excuses for ‘having eaten earlier’, pile their plates high with vegetables and salads to the exclusion of everything else, and organise a hectic schedule which means they often have to skip, or ‘are busy’ at meal times. When they do eat, there are rituals attached to food, such as cutting it into tiny pieces.
In the early stages of anorexia, people are cheerful, content and euphoric, with high levels of energy despite a low calorie intake and continued weight loss, suggesting they feel mentally alert and physically active. With successful dieting, they develop a sense of control over their body, and consequently their lives.
An individual’s exercise routine may be rigid and excessive, burning calories far in excess of consumption. When challenged about recent weight loss, they will deny they have a problem, believing they are still fat or parts of their body are huge. Their appearance provokes excessive personal criticism and a sideways glance in the mirror triggers expressions of extreme disgust and revulsion.
People with anorexia deny anything is wrong, despite obvious signs to the contrary. The physical consequences of their illness fail to alarm them. As starvation takes hold, they have difficulty in concentrating. They have mood swings, feel depressed and hopeless, lack motivation, often have anxiety or panic attacks, or feel claustrophobic in crowded places.
An individual with anorexia has a disturbed body image and will continue to defend their undernourished state. Even in a state of severe emaciation, they may insist their highly compromised physical state brings them benefits.
Why does anorexia develop?
There are many factors combining to cause anorexia. Recently, considerable progress had been made in our knowledge of key biological and psychological factors responsible for the development and maintenance of the illness. Visit the Research pages on this website to find out more about recent results and current projects.
People with anorexia have characteristic personality traits: they are perfectionists, fear making mistakes, extremely conscientious, attend to detail, and are often rigid in their thought processes.
People are vulnerable to developing anorexia if they have obsessive compulsive personality traits, and have ‘all or nothing’, ‘black and white’ thinking. These traits have normally been present in childhood and are accentuated during the acute stage of the illness. Starvation and weight loss appear to increase compulsive behaviour, and the onset of anorexia leads to a worsening of the rigidity and perfectionism. They personality traits persist after recovery, and are also often present in family members.
Many people with anorexia experience high levels of anxiety and avoid identifying and describing their own emotions. Research shows that people with anorexia avoid intense emotions and intimate interpersonal relationships, which are likely to arouse these emotions. The evidence suggests that starvation helps avoid difficult emotions, and people with anorexia see this as a benefit. They develop beliefs that starving themselves will help them stay safe and manage difficult emotions and the relationships.
Research teams are studying the brain mechanisms that contribute to our biological understanding of anorexia, and are investigating the biology of eating and how personality traits are linked to our response to food. Our research into the biological framework of the brain suggests that anomalies may exist in information and emotional processing.
Our research has shown that people with eating disorders, and anorexia in particular, perform extremely well in tasks that require an attention to detail, but this can be done at the cost of doing less well at seeing the ‘bigger picture’, putting the gist of information into context. People with anorexia are also good at remaining focussed, but not so good at adapting to changes in rules, especially if those changes are random events and not part of a system.
Our research has shown that the reaction of people with anorexia to food is abnormally wired up and entangled with other brain processes like emotion. Brain scanning studies have shown that parts of the brain activated in people with anorexia when shown images of food are different from the parts activated in healthy people interested in eating. In people with anorexia, the part of the brain that is involved in decision-making and emotional regulation – at the front above the eyes – abnormally kicks into action. Even when people have recovered from anorexia, the same brain area continues to be activated by food, which might explain why many people get trapped into anorexia.
Environmental factors also play an important role, both in the development and maintenance of the illness.
Someone is more likely to develop anorexia if their upbringing has been over-protective or over-controlled, if they have not been encouraged to think or act independently.
The physical consequences
Anorexia commonly starts in mid-adolescence when brain development undergoes significant changes. Poor provision of nutrients and/or raised levels of stress hormones associated with starvation have a deleterious effect on the developing brain and may alter its function in a lasting way.
Food deprivation leads to constipation; dizzy spells and faintness; abdominal pains; muscle weakness; poor blood circulation and feeling constantly cold; dry, rough discoloured skin; a swollen face, stomach and ankles; long, fine downy hair on face and body; and disrupted menstrual cycles.
There will be long-term damage to bones with loss of bone mass leading to osteoporosis and possible future fertility and serious reproductive problems. Women who become pregnant have high risk pregnancies and may subsequently have difficulties feeding their babies. Men with anorexia lose their libido.
Associated psychiatric problems include depression, alcohol and substance misuse, anxiety disorders and suicidal behaviour.
The quality of life of people with anorexia is severely impaired. A study on hospital admissions for adult psychiatric illness in England found that out of all diagnoses considered, eating disorders had the highest proportion of admissions with a length of stay over 90 days, and the longest median length of stay (36 days). An Australian study showed that eating disorders were in fourth place for women aged 15-24 among the leading causes of burden of disease in terms of years of life lost through death or disability.
