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What is anorexia?

Anorexia is characterized by the following features:

  1. Not maintaining body weight at or above minimally normal weight for the person's age and height.
  2. Intense fear of gaining weight or becoming fat, even though the person is objectively underweight.
  3. Disturbance in the way the person's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation or denial of the seriousness of current low body weight.
  4. In post-menarchal females, the absence of at least 3 consecutive menstrual cycles.

The above criteria are the formal requirements for a diagnosis of anorexia nervosa (from the Diagnostic and Statistical Manual of Mental Disorders). However, many people have some characteristics of anorexia without meeting formal criteria for a diagnosis. Also, many people with eating disorders fluctuate from anorexic to bulimic features.

Anorexia is a seriously debilitating disorder. People with anorexia achieve their low body weight by eating very little (starving), and/or by exercising excessively. They may also use large amounts of diet pills or laxatives. They avoid foods they view as 'fattening' and may go for long periods of time without eating. Some people with anorexia have periods in which their strict dieting regime collapses and they may 'over-eat'. This over-eating may not be excessive - it may be just a few pieces of bread - but for the anorexic this is viewed as a 'binge'.

Anorexia leads people to become quite secretive about their food habits. They may go to extraordinary lengths to hide the fact that they are starving themselves. Anorexics can engage in behaviours such as throwing away meals, avoid eating when other people are around, lie about how much they are eating, and they can take a very long time to eat small amounts of food.

The most striking psychological feature of anorexia is that in spite of being objectively underweight, the person's sense of their body is distorted, and they often view themselves as fat. The person they see in the mirror is different to what other people see. Anorexics are absolutely terrified of becoming fat, this is the fear that they live with every day, and this fear consumes them.

Because of this intense fear and distorted sense of their own body, combined with the physical effects of starvation, it can be very difficult for someone with anorexia to ask for help. This is because they may perceive treatment as bound to make them fat. It takes courage to ask for help.

How thin is too thin?

Being significantly underweight is difficult to categorically define. If a person has stopped menstruating and has a BMI of less than 18, these signs together would suggest the person is too thin.

How common is anorexia?

Research has shown that around 0.5-1% of young women meet diagnostic criteria for anorexia. Anorexia mainly affects teenage girls and young women, although the number of males suffering from anorexia is thought to be on the increase.

What causes and maintains anorexia?

There is no one 'cause' of anorexia. Anorexia is the result of a complex interaction of factors. Research has identified some of the factors that can give rise to the development and maintenance of anorexia:

Family background - studies have revealed that in the families of people with anorexia, there may be high expectations from caregivers to conform to rules and expectations. Children who grow up to develop anorexia may not be encouraged to develop independence from their family. In addition, parents who have eating problems may model anorexic type thinking styles and behaviour patterns which can become internalized by the child.

Social influences - today's cultural ideal for women (and, increasingly, for men), is extreme slimness. Magazines, celebrities, and fashion all propagate the idea that women should be rake thin. Additionally, peer pressure from other people is a powerful factor to consider. This idea is bound to influence young people, particularly during adolescence, when anorexia usually first develops.

Life events - as with many psychological issues, stressful life events may trigger the onset of anorexia, particularly if the life event occurs during a difficult developmental stage such as late childhood and early adolescence. The death of a parent, an illness, loss of a relationship, bullying, or sexual abuse are all examples of stressful life events that may trigger anorexia. Anorexia is much more likely to develop if the family background demonstrates characteristics such as those described above.

Thinking style - like bulimics, people with anorexia often display perfectionistic thinking patterns that tolerate no flaw in physical appearance, school work, academic performance, professional achievements, and relationships. Perfectionism in extreme form is highly destructive, as it is unrealistic (and not human!) to be 'perfect' in everything, all of the time.

Starvation Effects - once a person's body weight has dropped significantly, and little food is being consumed, the body is in a state of starvation. Starvation is associated with a number of psychological effects. One of these is that the person's ability to think flexibly is decreased. This is known as 'cognitive rigidity'. So, as the person's weight drops, their ability to think flexibly is also compromised, leading the anorexic thinking to become further entrenched.

Physical and psychological dangers associated with anorexia

The effects of starvation are extremely serious, both physically and psychologically. One important point about starvation is that it has a major impact on a person's psychological functioning, a fact that is often ignored. It may be surprising to note that some of the factors that people may have attributed to their own personality are in fact consequences of starvation.

Some of the psychological effects of starvation are listed below:

  • Mood swings
  • Irritability
  • Difficulty solving problems
  • Preoccupation with food
  • Poor concentration
  • Social withdrawal
  • Eating in secret
  • Rituals and specific ways of eating
  • Binge eating

Physical effects of starvation:

  • Poor circulation, leading to dizziness and fainting
  • Thinning bones (can increase risk of developing osteoporosis)
  • Irregular or missed periods
  • Constipation
  • Bloated or distended stomach
  • Poor immune system
  • Tiredness
  • Sleep problems
  • Poor temperature regulation
  • Weak bladder
  • Thinning skin, premature aging
  • Muscle weakness
  • Hair loss
  • Lanugo - soft, downy hair on the face, back, and arms
  • Low blood pressure
  • Kidney damage and failure
  • Heart attacks, heart failure
  • Seizures
  • Death (in extreme cases)

Psychological treatment of anorexia

On the basis of research findings, cognitive behaviour therapy(CBT) is viewed as one of the treatments of choice for anorexia (Family therapy is also recommended, particularly for younger sufferers, however Treat Yourself Well Sydney does not provide family therapy for anorexia). CBT for anorexia involves the following:

  • Assessment
  • Motivation to change - this is part of the assessment process, but also part of treatment, as it is common for anorexics to feel very ambivalent about changing. CBT works with people to help them increase their motivation to change. Treatment doesn't start until you feel ready to engage in change.
  • Education of the cognitive model of how anorexia was developed and how it is being maintained. This is done on an individual basis, as everyone's journey to anorexia is unique.
  • Education about starvation effects. Seeing a GP may be part of the treatment, to ensure that you are physically ok.
  • Agreement on eating and maintaining a goal weight. This is done collaboratively - meaning that you and your therapist will spend some time discussing what weight would suit you.
  • Self monitoring of eating, exercise and thinking patterns.
  • Introducing regular eating (this may include seeing a dietician).
  • Identifying thought distortions related to body image, eating, food, and exercise.
  • Challenging and changing thought distortions using cognitive techniques.
  • Behavioural experiments designed to challenge perfectionistic thoughts, problematic eating or exercise behaviours.
  • Teaching problem solving skills.
  • Working on body image.
  • Relapse prevention planning.

CBT will not make you fat. You will find that you are able to manage your weight at a healthy level without starving yourself or exercising obsessively. A normal life is possible!

Please note that if you are suffering from serious health issues as a consequence of the anorexia, out patient treatment may not be the wisest choice. Inpatient programs may be more appropriate if you are severely underweight. Visit www.cedd.org.au for more information about inpatient treatment programs for anorexia.

Treat Yourself Well Sydney clinical psychologists are experts in CBT treatments and have expert knowledge in the treatment of eating disorders. If you are interested in learning more about CBT for anorexia, give us a call at Treat Yourself Well Sydney. Why not do the brave thing - speak to someone today!