Navigating Anorexia Nervosa

Welcome to the ‘Navigating’ Series

We’re working our way through the various diagnoses that fall under the umbrella term of “eating disorder”. Even within these diagnoses there can be problematic restrictive behaviors that make diagnosis or identification of an eating disorder difficult. We include weight specifications, frequency of behaviors, and specific behavior breakdowns to narrowly fit only certain individuals into the criteria. For many people it might be more helpful to identify their experience as being primarily restrictive, compensatory, or maybe just that it involves uncomfortable overeating behaviors. This feels particularly true for people who fall under the umbrella of a restrictive eating disorder. We’ll talk about why that is in a second.

I notice that many people think that restrictive eating disorders are the most common way for someone to experience disordered eating. I think it goes back to health class and the images of emaciated, white females dominating the conversation about eating disorders. It may also tie to the misunderstanding that eating disorders are about desiring thinness or being “vain”. The reality is that anorexia is the least common eating disorder and even within this disorder many people have compensatory or bingeing behaviors. I talk about “restrictive” eating disorders more often than I really use the diagnostic title of anorexia because so many people experience restrictive behaviors outside of the context of the narrow diagnostic standards of anorexia nervosa. So, let’s get into it!

If you have any questions or additional considerations, please feel free to leave a comment!

Etiology

Restrictive eating disorders are commonly traced back to a desire for control when experiencing something difficult. It is a bit of a stereotype that does have some truth to it, but it is usually not the entire story. Once again, the restriction is usually serving a purpose to help cope with an event, experience, or just life itself. Restriction is commonly seen as the “desirable” eating disorder behavior as opposed to bingeing or purging. We associate restriction with discipline, losing weight, “successful” dieting, and an overcommitment to our health. It is hard for the general public to tell the difference between a diet and a restrictive eating disorder - oftentimes because diets are the precursor to the eating disorder. As things become more and more restrictive, there are important changes that start to occur related to the undernutrition.

Someone who is predisposed to a restrictive eating disorder has a slight difference in how their body reacts to undernutrition. We actually see that there are two important distinctions for those with anorexia than we see in the general public. First, for a person without anorexia, we see that when we feel hunger, then eat to satisfy that hunger, that after eating there is a reward response in our brains. AKA it feels good to eat food for most people. For someone with anorexia we don’t see that same feeling of satisfaction that comes after eating. On top of that, we also see that eating food might increase feelings of anxiety rather than helping to alleviate those feelings. These two variations in the psychology and biology of people with anorexia are part of the reason why they can maintain restriction for much longer than others and without having binge patterns break through. For the vast majority of people, their body will at some point get to the point where they feel out of control and turn to food. When this is the case, we get diagnoses like BED, bulimia, OSFED, or even just anorexia with binge/purge symptoms.

Beyond biology, we also live in an environment that is fueled by diet culture and beauty culture. The drive to fit into the impossible standards of the world can influence many people to experiment with dieting and restriction. Genetics and biology play their part in someone’s predisposition to developing an eating disorder, but then the environment, experience of trauma, inexperience with healthy coping behaviors, and many other life experiences are what fuel the development of disordered eating. Each story is different - no person’s eating disorder is really the same as someone else’s. The way our parents talk about food, our body shame, bullies, school education on food, exposure to dieting information, our traumatic experiences, having good models for coping, and friends can all play a role in our likelihood to turn to disordered eating that may progress to an eating disorder.

Behaviors, signs, symptoms

There are very strict diagnostic criteria to meet the definition of anorexia. Due to this we miss people who are in bigger bodies who are using these behaviors, we miss people who a typical healthcare practitioner might not deem “concerningly underweight”, and we miss people who might be good at talking through the positives of their diet (orthorexia). With that, we’ll start with the DSM criteria for anorexia and then, as always, get into my thoughts as a practitioner. To meet DSM criteria for anorexia you must have:

1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.

2. Intense fear of gaining weight or becoming fat, even though underweight.

3. 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 denial of the seriousness of the current low body weight.

4. (My addition) Even if all the DSM-5 criteria for anorexia nervosa are not met, a serious eating disorder can still be present. Atypical anorexia includes those individuals who meet the criteria for anorexia but who are not underweight despite significant weight loss. Research studies have not found a difference in the medical and psychological impacts of anorexia nervosa and atypical anorexia nervosa.

   
   

While these are the specific criteria one has to meet to receive a diagnosis of anorexia nervosa, there are many more behaviors that can show up in the patterns and dietary choices an individual is making. Restriction can go beyond just a limitation of energy or calories, and a person may be restricting food groups, food experiences, when they are allowed to eat certain foods, or overeating specific “safe” food groups while neglecting other important aspects of the diet. A restrictive eating disorder is commonly rigid in what foods are allowed, but also in the rituals and rules of how food is eaten. These specific rules and rituals help to maintain a sense of calm and control while the brain is typically overwhelmed with food thoughts that take up more than 50% of the day - sometimes up to 95% of the day. These obsessive thoughts about food and body are a sign of a malnourished brain, but in anorexia we see that they are misinterpreted as a distressing sign that the individual is a food obsessed, out of control human who can’t possibly be trusted to eat more. This cycle perpetuates the drive to further limit and control food options.

Anorexia commonly co-occurs alongside anxiety, depression, and OCD. There are many other mental health diagnoses that can occur at the same time as anorexia, but these are the most common. With anxiety and depression, it isn’t always clear what came first. Both of those disorders can impact hunger and fullness cues, motivation to eat, and the reward experiences of eating, but an eating disorder can also be shown to increase experiences of anxiety and depression. We should take all mental health experiences seriously during treatment and not “ignore” them until one disorder improves.

Treatment

Treatment for anorexia typically requires a lot of medical oversight and an understanding of the medical complications that can result from malnutrition. Of course, malnutrition can occur at any body size, so we are not gatekeeping restrictive eating disorder support from those who are not “clinically underweight”. Those who have lost weight or failed to gain appropriate weight - mainly adolescents, or those who are potentially undereating to prevent normal, healthy weight gain will all need to be assessed for their current intake as compared to their estimated needs. The dietitian will look at a dietary recall to see what current intake looks like and compare that to their calculation for expected energy needs. From there we may set a meal plan. I don’t provide a meal plan to all of my clients, but my clients with restrictive eating disorders almost always need some tangible guidance to understand how much food is really necessary for their healing. It is typically surprising for them to learn what an appropriate amount of food is, so having a guide to help them learn quantities can be helpful.

We also need to assess for any weight restoration needs in order to calculate estimated energy. Weight restoration is a slow process to help the body regain weight - both fat and muscle tissue - to get to a stable place where adequate intake and regular movement result in good health and stable body weight. In order to set a weight restoration goal, the RD will ask for a complete weight history, including adolescence, adult weight fluctuations, highest weight, lowest adult weight, and any history of dieting or other events that might impact weight gain and loss. For adolescents, the dietitian will ask for growth charts and evaluate how the child or teen has grown throughout their life in order to get them back “on track” with their expected growth trajectory. The quicker we are able to get on track with weight regain, the better the outcomes. Quick and efficient weight restoration is associated with lower risk of relapse and fewer health concerns during and after the recovery process. If a client isn’t able to restore efficiently in outpatient level of care, that is a sign that higher level of care may be necessary or helpful.

Since restrictive eating disorders are categorized by long term malnutrition, we are particularly careful with watching for potential medical complications. We will typically watch labs, monitor for GI dysfunction, and ensure that weight restoration is following an appropriate pace - not too fast or too slow. There are a few medication options to help support a more comfortable recovery, as well. At the core, we need to be re-establishing supportive eating patterns in order to help the body get back to a stable, healthy place. There is no ability to heal a malnourished body without finding a way to meet the nutritional needs of the individual through eating more food.

In sessions we might explore things like food exposures, fact checking, meal planning, and eating challenging foods together in order to push through the disordered thoughts that are common in anorexia. The dietitian will provide education about various nutrition concepts and help to counsel the client with any fears or disordered beliefs that aren’t supporting recovery. Taking an anti-diet approach helps to find balance and appreciation for food outside of just being “fuel”. A goal might be to work toward intuitive eating in the future, but the path to get there requires structure and routine.

Goals for Recovery

Similarly to other eating disorders, the goals for treating anorexia are two-fold. We are addressing the physical behaviors and medical complications that are present, and we are implementing strategies to improve mental health and the urges to use disordered behaviors. From the medical side, a person needs to be weight restored and stable in their supportive weight range prior to ending treatment. The client should be eating a wide variety of foods, multiple times per day, without feeling significant levels of distress or experiencing uncomfortable and persistent food thoughts all day. I want my clients to have a good understanding of their own food ethics and values - buying things that bring joy, sentimentality, and health into their lives. Obviously, at a minimum, labs should be normalized, and the major malnutrition related GI dysfunction should be improved and hopefully completely corrected1. On the mental health front, it is typical that we see an improvement in body image as healing progresses. This doesn’t mean that body image is completely resolved - we do live under the umbrella of diet culture - but that thoughts are less intrusive and consistent. We also see that people are able to respond to the disordered thoughts differently than in the past, being more kind to the body and ourselves. We should also see less anxiety with food and better self-confidence and self-trust when making food decisions and eating. Depending on the severity of the restriction, we may see better brain function like improved cognition, memory, and ability to focus. We also can see things like better humor - being able to laugh and find more joy in the day. Chronic malnutrition dulls our “bad” emotions, but it also dulls the fun ones. Eating enough and meeting our needs can actually help our full personality shine through which is one of my favorite things to experience as a clinician when I work with a client for a long time. And really, the major goal of treatment is to decrease suffering and increase joy in life. An eating disorder can create so much stress, isolation, fear, and tuning out of life that treatment is really just the best way to get back to a life that has normal ups and downs and room for feeling good.

If you have anorexia or are the caregiver to someone with a restrictive eating disorder, I hope this guide helps you in tailoring your treatment to your own needs and desires. I also hope it helps you in seeking out a professional to support you on your journey - ask questions and make sure the provider’s approaches are in line with your goals and needs. This is just an introduction to the basics of understanding and treating a complex mental and physical disorder. If you have more questions or want more information, please feel free to reach out via the comments or DM me.

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Unfortunately, not all people who recover from an eating disorder completely recover their GI function and may experience uncomfortable bloating, slow stomach emptying, constipation, diarrhea, etc. even after recovery. There is also a higher risk of developing disordered eating if you already have GI issues, so if your eating disorder starts as a way to cope with IBS, IBD, Celiac Disease, or any other GI disorder, it will not be magically resolved by recovering.