Anorexia Nervosa

Also Listed As: Eating Disorders, Anorexia

People who intentionally starve themselves into an emaciated state yet remain convinced that they are overweight are suffering from a condition known as anorexia nervosa. Anorexia is a severe emotional disorder that is increasingly common, especially among young women in industrialized countries where cultural expectations encourage women to be thin. Fueled by popular fixations with thin and lean bodies, anorexia is also affecting a growing number of men, particularly athletes and those in the military. People with anorexia are terrified of becoming obese and refuse to maintain a normal weight, putting themselves in danger of starvation.

Anorexia rarely begins in people who are older than 40 years of age. It most commonly appears in the teenage years, affecting up to 3 in 100 adolescents. Although anorexia seldom emerges before puberty, associated mental conditions, such as depression and obsessive-compulsive behavior, are usually more severe when it does. The onset of anorexia is often preceded by a traumatic or stressful event and it is usually accompanied by other emotional difficulties. Anorexia is a life-threatening condition that can result in death from starvation, heart failure, electrolyte imbalance, or suicide.

There are two main types of anorexia nervosa:

Signs and Symptoms

The primary sign of anorexia nervosa is severe weight loss, accompanied by any number of physical and psychological symptoms and unusual behaviors related to food, eating, or exercise. A person for whom a healthy weight would be 125 pounds, for example, may drop 20, or even as much as 60 pounds below this. At the same time, the person may insist that he or she is overweight.

Physical Signs Psychological Signs Behavioral Symptoms


There is no specific cause of anorexia. Medical experts agree that several factors work together in a complex fashion to lead to the eating disorder. These may include:

Risk Factors


While your healthcare provider will rely on points discussed in Signs and Symptoms such as excessive weight loss, refusal to maintain normal body weight, and distorted self-perception, he or she will also ask a series of questions to better determine whether or not anorexia is present. The SCOFF questionnaire, developed in Great Britain, is proving to be a very reliable method for diagnosing anorexia. A "yes" response to at least two of the following questions is a strong indicator of an eating disorder: If an eating disorder is suspected, the healthcare provider will order a number of laboratory tests. These serve to determine blood count (to assess for signs of anemia that may be related to lack of iron or vitamin B12), levels of electrolytes (minerals such as potassium, calcium, and magnesium), amylase (serum amylase is elevated when there is frequent vomiting), and protein, and kidney, liver, and thyroid functions. He or she may also order an electrocardiogram (which gives a graphic record of the electrical activity of the heart); this may be abnormal if there is a deficiency in an electrolyte or nutrient such as potassium or calcium. If a diagnosis of anorexia is made, the healthcare provider will require frequent office visits to monitor the condition. It is best for a person with anorexia to work with a multidisciplinary team including his or her primary care physician, a psychologist or psychiatrist, and a registered dietitian.

Preventive Care

The most effective prevention strategy is the development, from an early age, of healthy eating habits and a strong body image. Cultural values that place a premium on lean or thin bodies need to be questioned. Education about the life-threatening nature of anorexia is also an important part of prevention.

In those who have already been diagnosed and treated for anorexia, avoiding recurrence of the eating disorder is the primary goal.

Treatment Approach

Anorexia demands a multipronged treatment plan that addresses both the physical and psychological aspects of this disorder. Cognitive-behavioral therapy, often in combination with antidepressants, is a very effective therapeutic approach for treatment of eating disorders. Complementary and alternative methods of treatment (such as the use of herbs and mind/body medicine) are valuable adjuncts to usual ways of stimulating appetite, addressing nutritional problems, and helping the patient to develop a healthier body image and to learn to deal more productively with stress.

In general, the most important aspect of treating anorexia is restoring weight and preventing starvation. For this, hospitalization may be necessary, particularly under the following circumstances: Generally, adequate weight gain (1 to 2 pounds per week) and appropriate changes in behavior require a 10 to 12 week hospital stay. (Most insurance in the United States, however, covers only 15 days of inpatient treatment.) To avoid bloating, abdominal upset, and fluid retention, those who are severely malnourished may be started on a diet of 1,500 calories a day, gradually increasing to as much as 3,500 calories. Because anorexia triggers changes in metabolism, high caloric intake may be necessary to stimulate weight gain.

Unfortunately, there is no completely effective treatment for anorexia nervosa, and recovery can take many years. Even after some weight gain, many people with anorexia remain quite thin and risk of relapse is very high. A number of influences in the social environment may make recovery difficult: Soliciting the involvement of friends, family members, and others in the treatment of the individual, with education for everyone regarding the gravity of the disease, may diminish these influences.


Treating anorexia nervosa involves major lifestyle changes. Not only must eating habits be altered, but the individual must adjust his or her self perception to no longer hold a distorted body image. The following lifestyle changes may help in this process:


Anorexia nervosa in some ways resembles other major psychiatric disorders such as depression and obsessive-compulsive disorder, because some of the symptoms of these disorders, for example obsessive behavior, lack of enjoyment from life, and severely distorted perception of reality (in this case, of the body), are exhibited by people with anorexia. This has led to the use of antidepressants for anorexia, particularly selective serotonin reuptake inhibitors (SSRIs), because these drugs are first-line treatments for OCD and depression. Medications, however, do not work alone and must be used in conjunction with a multidisciplinary approach that includes nutritional interventions and psychotherapy.

Serotonin Reuptake Inhibitors
Studies suggest that fluoxetine may increase weight and improve mood over several months in people with anorexia nervosa and depression. Similarly positive results were obtained in a preliminary study of anorexics whose body weight had already been partly restored.

Tricyclic Antidepressants
This class of antidepressants, including imipramine and desipramine, tend to be more effective for bulimia than anorexia. One study suggests that clomipramine has the potential to stimulate weight gain and improve symptoms of anorexia, but more research is needed on the value of this drug in treating this particular eating disorder.

In a study using high doses of cyproheptadine hydrochloride, which is thought to stimulate appetite, the number of days necessary to achieve appropriate weight gain were decreased and depression was relieved in those with restricting type anorexia.

Estrogen together with progesterone may be used to restore normal menstrual cycles. This, however, does not generally have any effect on weight.

Nutrition and Dietary Supplements

Anorexics with low body weight, low BMI, and low serum albumin (the main protein in blood) levels are at increased risk for vitamin and mineral deficiency. Vitamin abnormalities may contribute to cognitive difficulties such as poor judgment or memory loss and other psychiatric conditions. These deficiencies can often be corrected with dietary interventions. Therefore, an important part of treatment is to include a multivitamin with minerals (particularly calcium).

Vitamin B Complex
Deficiencies in vitamins B2 (riboflavin) and B6 (pyridoxine) have been noted in those with anorexia, with some studies suggesting that deficiency of these B vitamins is present in approximately 20% of anorexic patients admitted to the hospital for treatment. One small study of 13 people with anorexia found 33% of the participants were deficient in vitamins B2 and B6 may be deficient in as many as 33% of those with this eating disorder. Dietary changes alone, without additional supplements, often can bring vitamin B levels back to normal.

Inadequate intake of calories, protein, and micronutrients over a prolonged period of time, as seen in people with anorexia, may cause oxidative stress, particularly when coupled with excessive physical activity. Oxidative stress is a process in which certain substances in the body generated from metabolism (breakdown of tissue for energy) cause cell damage. Antioxidants, such as vitamins A, C, and E, are substances that can help protect the body from the damage of oxidative stress. In a study comparing antioxidant levels in healthy female adolescents to those with anorexia, researchers found that the anorexic group had reduced amounts of these protective substances, such as vitamin E, and that the antioxidants were not as active in the blood as they normally would be. It is unclear, however, whether supplementation with antioxidants including vitamins E and C, beta-carotene, coenzyme Q10, and selenium will correct deficiencies in people with anorexia or improve their treatment in any way. Currently, supplementation with antioxidants is not part of standard care for anorexia, but is being explored scientifically.

Zinc influences appetite, taste, smell, vision, and cognitive function and is an essential nutrient for protein synthesis, growth, and wound healing. The symptoms of zinc deficiency include loss of appetite, weight loss, skin abnormalities, lack of menstruation, and depression. Studies have revealed that zinc deficiencies are common in those with anorexia nervosa and may contribute to a number of the symptoms of the condition.

Zinc supplementation has demonstrated the following benefits in anorexics: While zinc supplementation may be helpful as an addition to standard treatment for anorexia, there are a number of different forms of zinc and more research is needed to determine which is most effective and at what dosage.

Dehydroepiandrosterone (DHEA)
Women with anorexia nervosa are at increased risk for bone fractures and can develop osteoporosis at a younger age than women without eating disorders. It has been observed that adolescents and young adults with anorexia nervosa tend to have low levels of DHEA, a hormone produced by the adrenal glands. This is important because DHEA levels have been associated with bone mineral density, suggesting that this hormone may play a role in preventing bone loss and stimulating bone formation. Some preliminary studies suggest that women with anorexia who take 50 mg of DHEA per day are able to restore normal levels of this and other hormones, such as estrogen and testosterone, and show signs of protection from bone loss.

Essential Fatty Acids
Polyunaturated fatty acids (PUFAs), such as gamma-linolenic acid (an omega-6 fatty acid) and alpha-linolenic acid (an omega-3 fatty acid), are essential for normal growth and development. They are not made by the body and must therefore be obtained through the diet. Studies suggest that women, and possibly men, with anorexia nervosa have lower than optimal levels of PUFAs and display abnormalities in the use of these fatty acids in the body. To prevent the metabolic complications associated with essential fatty acid deficiencies, some recommend that treatment programs for anorexia nervosa include PUFA-rich foods such as organ meats and fish.

Melatonin is a hormone produced in the brain that regulates sleep. Studies show that fluctuations in melatonin levels may influence the symptoms of anorexia. For example, abnormally high melatonin levels may cause depressed mood and daytime sleepiness in those with anorexia. While people with restricting type of anorexia usually have normal melatonin levels, studies have found that those with binge and purge anorexia, and anorexia in combination with depression have abnormal fluctuations and levels of melatonin. Melatonin levels may play a role in the symptoms of anorexia, but it is not known whether supplementation will change the course of the disease. Some researchers speculate, however, that melatonin levels in people with anorexia may indicate who is likely to benefit from antidepressant medications.


While the following appetite stimulants have not been studied for the treatment of anorexia nervosa, they have been used in certain traditional healing systems to stimulate appetite and may be recommended as a complementary therapy by an herbal specialist: In cases of significant weight loss where the muscles begin to deteriorate, some herbalists may recommend fenugreek seed (Trigonella foenum-graecum). Skullcap (Scutellaria lateriflora) may be used to relax the nerves and Roman chamomile (Chamaemelum nobile) may be used to treat depression associated with anorexia.

Massage and Physical Therapy

Massage appears to be a helpful component of treatment for anorexia nervosa. In one study, a group of adolescents with anorexia received massages twice weekly for one month, in addition to standard daily group therapy. The massaged adolescents reported lower anxiety levels and improved body image compared to adolescents with anorexia receiving only standard daily group therapy. Measurably reduced cortisol (a marker of stress) and increased dopamine (a brain chemical associated with relaxation) concentrations were also observed in the treatment group.


A professional homeopath can provide supportive care to address various aspects of anorexia. Because of the seriousness of the condition, anorexic people are advised against treating themselves with homeopathic remedies.

Mind/Body Medicine

Cognitive Behavioral Therapy
Cognitive-behavioral therapy is reported to be one of the most effective therapies for anorexia. It is based on the assumption that anorexia develops in response to life stresses. Treatment is aimed at confronting the individual's fears and avoidance behaviors and cultivating new problem-solving skills. It also aims to increase awareness of negative thought processes and to change them. Cognitive techniques are used to encourage patients to evaluate and challenge their automatic thoughts, examine their underlying assumptions, and replace them with realistic beliefs and actions based on reasonable self-expectations.

Family Therapy
Family therapy is recommended for both children and adults, in addition to individual therapy for the person with anorexia. Parents and other family members often have intense feelings of guilt and anxiety that they need to address. They may actually support the individual's eating disorder out of these feelings or perhaps they, too, put a premium on being thin. Family therapy is aimed, in part, at helping the parents or partner (in the case of an adult) understand the medical gravity of this illness and the ways in which they may be inadvertently contributing to it.

Hypnosis has been shown to be successful as part of an integrated treatment program for anorexia nervosa. Evidence suggests that purging anorexics have a greater hypnotic ability—and thus may be more likely to benefit from hypnosis—than restrictive anorexics. Hypnosis reportedly strengthens both self-confidence and the ability to cope, which may result in healthier eating, improved body image, and greater self-esteem. Whether or not the treatment is successful may depend on the number of sessions; individual programs have generally involved 1-hour per week for 3 months followed by bi-weekly sessions until treatment is no longer needed.

Studies suggest that biofeedback may be helpful in reducing stress in people with anorexia.

Other Considerations

Pregnancy Anorexia poses a number of potential problems for the woman who is pregnant or wishes to become pregnant:

Prognosis and Complications

Medical complications associated with anorexia include: The outlook for individuals with anorexia is variable, with recovery taking between 4 and 7 years. There is also a high chance of disease recurrence even after recovery. Long-term studies show that 50% to 70% of people recover from anorexia nervosa; however, 25% do not fully recover. Many, even after they are considered "cured," continue to exhibit traits of anorexia such as remaining very thin and striving for perfection.


Anorexia Nervosa. NMIHI. Accessed at on September 12, 2018.

Anorexia nervosa. Symptoms and causes. MFMER. Accessed at on September 12, 2018.

Birmingham CL, Goldner EM, Bakan R. Controlled trial of zinc supplementation in anorexia nervosa. Int J Eating Disord. 1994;15:251-255.

Biederman J, Herzog DB, Rivinus TM, et al. Amitriptyline in the treatment of anorexia nervosa: a double-blind, placebo-controlled study. J Clin Psychopharmacol. 1985;5(1):10-16.

Blumenthal M, Goldberg A, Brinkman J, ed. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications and American Botanical Council; 2000.

Crisp AH, Lacey JH, Crutchfield M. Clomipramine and 'drive' in people with anorexia nervosa: an inpatient study. Br J Psychiatry. 1987;150:355-358.

Field T. Massage therapy effects. Am Psychol. 1998;53:1270-1281.

Gordon C, Grace E, Emans SJ, Goodman E, Crawford MH, Leboff MS. Changes in bone turnover markers and menstrual function after short-term oral DHEA in young women with anorexia nervosa. J Bone Miner Res. 1999;14:136-145.

Gross HA, Ebert MH, Faden VB, Goldberg SC, Nee LE, Kaye WH. A double-blind controlled trial of lithium carbonate primary anorexia nervosa. J Clin Psychopharmacol. 1981;1(6);376-381.

Halmi KA, Eckert E, LaDu TJ, Cohen J. Anorexia nervosa. Treatment efficacy of Cyproheptadine and amitriptyline. Arch Gen Psychiatry. 1986;43(2):177-181.

Gabapentin. NMIHI. Accessed at on September 12, 2018.

Holman RT, Adams CE, Nelson RA, et al. Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids. J Nutr 1995;125:901-907.

Humphries L, Vivian B, Stuart M, McClain CJ. Zinc deficiency and eating disorders. J Clin Psychiatry. 1989;50:456-459.

Eating Disorders. MedlinePlus. Accessed at on September 12, 2018.

Kennedy SH. Melatonin disturbances in anorexia nervosa and bulimia nervosa. Int J Eating Disord. 1994;16:257-265.

Kleifield EI, Wagner S, Halmi KA. Cognitive-behavioral treatment of anorexia nervosa. Psychiatric Clin N Am. 1996;19:715-737.

McClain CJ, Stuart M, Vivian B, et al. Zinc status before and after zinc supplementation of eating disorder patients. J Am Col Nutr. 1992;11:694-700.

McNulty. Prevalence and contributing factors of eating disorder behaviors in active duty Navy men. Mil Med. 1997;162(11):753-758.

Miller LG, Murray WJ, eds. Herbal Medicinals: A Clinician's Guide. New York, NY: Pharmaceutical Products Press; 1998.

Moyano D, Sierra C, Brandi N, et al. Antioxidant status in anorexia nervosa. Int J Eating Disord. 1999;25:99-103.

Psychiatric medications. NMIHI. Accessed at on September 12, 2018.

Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Ped Int. 2000;42:76-81.

Rock CL, Vasantharajan S. Vitamin status of eating disorder patients: Relationship to clinical indices and effect of treatment. Int J Eating Disord. 1995;18:257-262.

Safai-Kutti S. Oral zinc supplementation in anorexia nervosa. Acta Psychiatr Scand Suppl. 1990;361(82):14-17.

Shay NF, Manigan HF. Neurobiology of zinc-influenced eating behavior. J Nutr. 2000;130:1493S-1499S.

Vandereycken W, Pierloot R. Pimozide combined with behavior therapy in the short-term treatment of anorexia nervosa. A double-blind placebo-controlled cross-over study. Acta Psychiatr Scand. 1982;66(6):445-450.

Wiseman CV, Harris WA, Halmi KA. Eating disorders. Medical Clin N Am. 1998;82:145-159.

What are the symptoms of anorexia? Office on Women's Health. Accessed at on September 12, 2018.

Wolfe BE, Metzger ED, Jimerson DC. Research update on serotonin function in bulimia nervosa and anorexia nervosa. Psychopharmacol Bull. 1997;33:345-354.

Young D. The use of hypnotherapy in the treatment of eating disorders. Contemporary Hypnosis. 1995;12:148-153.