An emotional disorder characterized by severe and potentially life-threatening weight loss through self-induced reduction in total food intake. More than 90% of reported cases occur in women in industrialized countries where thin bodies are considered attractive, though anorexia now occurs in a growing number of men. Although seldom appearing prior to puberty, associated mental disturbances are usually more severe when it does. Mean onset is 17 years; it rarely begins after age 40; onset is often associated with a stressful event; prevalence is 0.5% to 1.0% when full diagnostic criteria are met—higher for subthreshold diagnosis (Eating Disorders Not Otherwise Specified). Death may result—usually caused by starvation, suicide, heart failure, or electrolyte imbalance.

Two subtypes:

• Restricting Type: Dieting, fasting, or excessive exercise
• Binge-Eating/Purging Type: Regular binge-eating, and/or purging by self-induced vomiting and/or misuse of laxatives, enemas, and/or diuretics. Binge-eating may not occur; purging is common even after small amounts of food have been eaten.

Full diagnostic criteria:

• Refusal to maintain minimum body weight for age and height
• Unrealistic fear of weight gain
• Distorted perception of personal body shape and/or size; denial of seriousness of low body weight
• Amenorrhea

• Psychopathological fear of biological and psychological maturity
• Severe trauma during puberty or pre-puberty (death of a loved one; sexual abuse)
• Abnormalities with neurotransmitters (dopamine, serotonin, norepinephrine, and endogenous opioids)

• Heredity in 20% of cases compared to 6% in other psychiatric illnesses. Incidence higher among first-degree relatives (2% to 10% among mothers and sisters of anorectic women); and monozygotic twins (9 of 16) as opposed to dizygotic twins (1 of 14)
• Co-morbid depression in most patients
• Obsessive-compulsive and/or sensitive-avoidant personalities more vulnerable
• Significant increase in risk among normal dieters
• Societal attitudes place some individuals at higher risk (e.g., dancers, runners, models, jockeys, wrestlers, actresses/actors)

• Significant weight loss, or emaciation
• Depressive symptoms (depression, social withdrawal, irritability, insomnia, diminished sex drive)
• Obsessive-compulsive behavior related to eating or other activities
• Denial
• Distorted perception of physical self
• Preoccupation with body size, image, weight control
• Preoccupation with food (collecting recipes; hoarding food)
• Reluctance to eat in public
• Feelings of ineffectiveness
• Excessive need to control personal environment
• Rigid thinking
• Limited social spontaneity
• Excessively restrained initiative and emotional expression

• Physical disorders
• Tumors
• Bulimia
• Superior Mesenteric Artery Syndrome
• Major Depressive Disorder
• Schizophrenia
• Social Phobia
• Obsessive-Compulsive Disorder
• Body Dysmorphic Disorder

• Substantial weight loss unexplainable medically
• Emaciation
• Hypothermia
• Hypotension
• Hypocaratenemia
• Constipation
• Abdominal pain
• Cold intolerance
• Lethargy
• Excess energy
• Lanugo on trunk
• Brachycardia
• Eroded tooth enamel (from vomiting)
• Scars/calluses on dorsum of hand (from teeth during induction of vomiting)
• Dry skin, thinning hair

Abnormal findings are primarily due to starvation:

• Hematology: leukopenia, mild anemia and—rarely—thrombocytopenia
• Chemistry: dehydration, hypercholesterolemia, elevated liver function tests, metabolic alkalosis, hypochloremia, hypokalemia, metabolic acidosis, low levels of serum thyroxine and triiodothyronine, hyperadrenocorticism, and low serum estrogen/testosterone
• Electrocardiography: sinus bradycardia and arrhythmias
• Electroencephalography: abnormalities caused by fluid and electrolyte disturbances
• Resting energy expenditure: may be significantly reduced

• Hypotension and bradycardia
• Peripheral edema

Evaluation of signs and symptoms after eliminating depressive disorders and/or medical conditions as primary

Treatment is lengthy and challenging; relapse is common and preoccupation with dieting and weight usually continues. The greater the time between symptom onset and treatment commencement, and/or presence of personality disorders, the less likelihood of success. Controlling the fear of abnormal body weight and relieving feeding anxiety must be central and awareness of potential medical risks is important. Treatment must be tailored to the individual as integrated treatment is most beneficial. Patients are at greater risk of osteoporosis and lifelong problems with depression/anxiety. Many patients with anorexia may be quite accomplished at carrying extra weight on their bodies when being weighed and are addicted to the heightened sensations of starvation. Support groups may actually be damaging if the patient is competitive and attends groups to get ideas on deceiving care givers. Other general treatment strategies may include the following.

• Cognitive-behavioral/educational approaches—psychoeducational principles focusing on personal, inter-relational, and social conflicts; fears/misconceptions about eating; supervised exercise programs; body image therapy
• Psychodynamic, feminist, and family approaches—self-psychological methods; consultation and therapeutic engagement; family therapy
• Special issues—managing medical/comorbid medical consequences and/or substance abuse/dependence; traumas and/or sexual abuse; refusal of treatment; group psychotherapy; self-help
• Inpatient and/or partial hospitalization in severe cases

Antidepressants appear to be helpful only after intensive psychotherapy, attainment of normal weight, and development of good eating patterns.

Alternative therapies may be especially helpful in patients who have fixated on avoiding anything "artificial." Treatment is long with frequent setbacks. Herbs can be effective in both calming anxiety and stimulating digestion. "Systematic desensitization" through muscle relaxation with visual imagery can be helpful.

• Zinc (15 mg/day increased to 50 mg bid)—may improve mood and appetite, may be most useful at increasing the accuracy of body image
• Protein supplements (1 to 3 servings a day)—will help insure sufficient amino acids and prevent wasting. Some protein supplements are low in calories, which may make the patient more willing to consider this therapy.
• Multivitamin—A well-rounded multivitamin will help to compensate for dietary deficiencies. Due to ease of assimilation, a vitamin made from whole food concentrates is more effective in eating disorders.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Goldenseal (Hydrastis canadensis): a strong digestive stimulant, and tonic to the digestive tract, is a specific to anorexia nervosa
• Condurango (Marsdenia condurango): alterative and digestive stimulant, where there is diminished appetite or dietary abuse is a specific to anorexia nervosa
• Licorice (Glycyrrhiza glabra): antidepressant effects, heals mucous membranes of the digestive tract, regulates cortisol release, modulates estrogen effects; contraindicated in hypertension, may cause peripheral edema (pseudoaldosteronism), which resolves when licorice is discontinued
• Wild yam (Dioscorea villosa): hormone balancing, antidepressant, supports adrenals, antispasmodic
• Valerian (Valeriana officinalis): sedative, digestive bitter, and appetite stimulant
• Lemon balm (Melissa officinalis): mild sedative, spasmolytic, may gently help regulate TSH and thyroid function
• Oatstraw (Avena sativa): nerve tonic, antidepressant, demulcent, historically used for general debility with nervous exhaustion; this herb is slow to start acting but long-lasting.
• St. John's Wort (Hypericum perforatum): restorative nervous system tonic specific in use in depression or anxiety states that have led to fatigue and adrenal exhaustion
• Fenugreek (Trigonella foenum-graecum): nutritive and digestive tonic used where there is digestive debility and poor nutrition; traditionally used in muscle wasting states or where there is great weight loss; saw palmetto can be used as an alternative to fenugreek.
• Saw palmetto (Serenoa repens, Sabal serrulata): digestive tonic and connective tissue rebuilder; traditionally used to prevent muscle wasting and general debility
• Siberian ginseng (Eleutherococcus senticosus): a supportive adaptogen used to improve vitality and stamina

Acute homeopathics may be helpful during acute illness. For appropriate constitutional prescribing, which can be helpful, consult a homeopath.

May be helpful in restoring energy and reducing stress.

May be helpful if patient is willing to be touched. Essential oils (lavender, rosemary, verbena) can be added to the massage to increase its effect.

• Long-term monitoring and support is necessary, particularly in severe cases. Prognosis deteriorates significantly without long-term follow-up care.
• Follow daily activity patterns, rituals

• Intravenous nutritional supplements, multivitamins, and potassium may be necessary in severe cases.
• Because the disorder is primarily psychological and not simply appetite loss, psychotherapy is usually necessary to establish normal eating patterns.
• Seek professional care from specialists in eating disorders

• Education about serious related medical problems
• Intervention programs
• Developing skills to cope with social fixation on thinness and dieting
• Sufficient zinc intake/absorption

• See Laboratory subhead
• Starved patients have greater sensitivity to medications in general
• Cardiac arrhythmia and arrest
• Necrotizing colitis
• Hypokalemia

• Prognosis is variable
• Long-term (4 to 30 years) mortality rate is more than 10%
• Manifestation in early adolescence usually indicates a more optimistic prognosis.
• Long-term studies show 50% to 70% of patients are no longer clinically anorectic but many (presumably those doing the poorest) drop out; 25% show poor outcomes and chronic illness; and, in a given 10-year period, 5% die—usually from complications, suicide, or cardiac arrest.

Possible problems include:

• Difficulty conceiving/carrying to term
• Miscarriage
• Parental malnourishment as fetus grows, particularly calcium
• Exacerbation of medical complications
• Retarded, slow, weaker, and smaller offspring at risk of inheriting the disorder
• Stress of pregnancy and/or parenthood may trigger a relapse

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

Balch JF, Balch PA. Prescription for Nutritional Healing. 2nd ed. Garden City Park, NY: Avery Publishing Group; 1997.

Garner DM, Garfinkel PE, eds. Handbook of Treatment for Eating Disorders. 2nd ed. New York, NY: The Guilford Press; 1997.

The Harvard Mental Health Letter. October & November, 1997.

Kalasky KL, ed. The Alternative Health & Medicine Encyclopedia. 2nd ed. Detroit, Mich: Gale Research; 1998.

Kaplan AS, Garfinkel PE, eds. Medical Issues and the Eating Disorders—The Interface. New York, NY: Brunner/Mazel Publishers; 1993.

Shils ME, Olson JA, Shike M, ed. Modern Nutrition in Health and Disease. 8th ed. Philadelphia, Pa: Lea & Febiger; 1994:2.

Werbach MR. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing Inc; 1987.