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Monitoring your food intake, saving hundreds of recipes, counting calories, working out constantly, measuring your body, and checking yourself in the mirror for improvement may seem like healthy habits if you’re trying to lose weight. But when this body preoccupation becomes obsessive, these habits may become unhealthy and indicate an eating disorder. Anorexia is ten times more common among women than men and usually begins in adolescence or young adulthood (American Psychiatric Association, 2013).
It’s very uncommon for people with anorexia to seek help on their own. Often, they do not acknowledge that they’ve lost weight or recognize the severity of their weight loss until they have distressing physical or psychological consequences that warrant medical attention. It’s usually a concerned family member who brings the issue to a professional’s attention. Anorexia is a serious mental disorder that may require hospitalization due to the refusal to eat and the resulting potentially fatal medical conditions (Wonderlich et al., 2020). If you’re worried about yourself or a loved one, you can take the National Eating Disorders Association’s (NEDA) confidential screening or call 800.931.2237. You can also find treatment and support groups on NEDA’s site. And you can learn more about supporting a friend or family member with an eating disorder in this goop Q&A with psychologist Gia Marson.
Symptoms of Anorexia Nervosa
Anorexia is a restriction of food intake that may lead to dangerously low body weight. Attempts to lose weight or prevent weight gain may be through dieting, fasting, excessive exercise, or purging (vomiting). There are two subtypes of anorexia. One is restricting, when food intake is severely limited. The second is when binge eating is followed by purging in order to maintain a very low body weight.
It’s important to be clear: Anorexia is an illness, whereas dieting is not. People with anorexia are not only constantly preoccupied with activities to prevent weight gain, but they also have a distorted perception of how their body looks.
The symptoms of anorexia nervosa overlap with other eating disorders. Atypical anorexia may involve similar behaviors but is not associated with low body weight. Similarly, in bulimia nervosa bingeing and purging is not associated with very low body weight (Yilmaz et al., 2015).
Many people with anorexia develop a condition called lanugo in which the body covers itself in a layer of downy hair for insulation as the body desperately tries to keep itself warm. Fingertips may turn blue due to lack of proper circulation. The skin may also become dry and turn yellow. People may also feel tired or have trouble sleeping.
Potential Causes and Related Health Concerns
Eating disorders are believed to be caused by a complex and poorly understood interplay between genetics and environmental factors such as trauma, family dynamics, or learned behavior. The risk of developing anorexia is four to eleven times higher in women if they have a relative with anorexia. From research on twins, it seems clear that a significant portion of the risk of developing anorexia is inherited (Watson et al., 2019; Yilmaz et al., 2015).
Are Parental Styles at the Root of Eating Disorders?
Several studies have suggested that overprotective and critical parents as well as changes in family structure (a parent leaving) are risk factors for the development and maintenance of eating disorders. But in 2009, the Academy for Eating Disorders released a position paper refuting the idea that these family factors are the primary cause of eating disorders, arguing that this is an oversimplification (Le Grange, Lock, Loeb, & Nicholls, 2009).
It’s important for people with anorexia to work with a therapist to determine what the underlying cause of their disorder is. If it’s trauma, they’ll likely need to work through that to fully recover. If it’s family dynamics, family-based treatment has been shown to be effective among adolescents. For more therapy options, see the conventional treatments section. And to learn more about the potential connection between trauma and eating disorders, see our Q&A with psychologist Gia Marson.
Long-Term Health Complications
Anorexia can cause extreme health complications and should be taken seriously. At its worst, anorexia can cause organ failure and death. It can cause irregular heart rhythms, which may lead to heart failure. Malnutrition may cause a loss of bone density and increase the risk of broken bones. Starving the body can result in dangerously low blood sugar, infertility, and lack of menstrual periods.
Purging by vomiting can damage the esophagus and cause teeth to erode. It leads to a dangerous loss of electrolytes needed for normal muscle and heart function, including potassium. Purging by abusing laxatives was thought to result in colon muscles no longer being able to contract by themselves, but this appears to have been associated with a type of laxative no longer in use (Forney et al., 2016; National Eating Disorders Association, 2017).
Mental Health and Anorexia
Anorexia often presents with co-occurring anxiety, depression, or other mental health disorders.
Anorexia is marked by obsessive behaviors related to food. People may hoard food, collect recipes, or have careful rituals around their eating or exercising. These behaviors are often intended to help them establish control, which is a key component of anorexia. If individuals also have obsessions and compulsions not related to food, they may also be diagnosed with obsessive-compulsive disorder (OCD). One study reported that 64 percent of those with eating disorders also have at least one anxiety disorder and 41 percent have OCD. One hypothesis is that anxiety disorders predispose people to developing an eating disorder (Kaye, Bulik, Thornton, Barbarich, & Masters, 2004). It’s important to recognize, diagnose, and treat mental health issues as early as possible.
Where Can You Go for Help?
Every decade, 5.6 percent of people with anorexia die (either from health complications or suicide), making it the deadliest psychiatric illness of all (Yager et al., 2006). If you are in crisis, please contact the National Suicide Prevention Lifeline by calling 800.273.TALK (8255) or the Crisis Text Line by texting HOME to 741741 in the United States.
How the Different Forms of Anorexia Are Diagnosed
Anorexia nervosa is classified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a feeding and eating disorder. The diagnostic criteria for anorexia nervosa include restriction of energy intake that leads to low body weight, intense fear of gaining weight, and behavior that interferes with weight gain. It also includes issues with body weight perception and self-esteem related to body weight. For example, women may see themselves as overweight when they are actually dangerously thin. Their self-esteem may be unusually dependent on how they perceive their body weight.
Subtypes of Anorexia
There are two subtypes of anorexia nervosa. The restricting subtype is defined as weight loss accomplished through dieting, fasting, and/or excessive exercise without bingeing and purging behavior. The binge eating and purging subtype is defined as engaging in recurrent episodes of binge eating or purging behavior in the past three months. (This is different from bulimia nervosa, which is characterized by purging but does not include calorie restriction.) There also may be crossover between the two different subtypes of anorexia nervosa, and individuals may experience anorexia and bulimia at different points in their lives.
What Is Considered a Severe Anorexia Diagnosis?
To determine the severity of an anorexia nervosa diagnosis, body weight and height are used to calculate the body mass index (BMI). For children and adolescents, BMI percentile is used instead. For adults, a BMI of 18.5 to 24.9 is thought to be healthy. A BMI of 17 or higher is considered to be mild anorexia, moderate anorexia is a BMI of 16 to 16.99, severe anorexia is a BMI of 15 to 15.99, and extreme anorexia corresponds to a BMI less than 15. If individuals have severe functional disability, the level of severity may be escalated, regardless of their current weight (Harrington et al., 2015).
Atypical Anorexia Nervosa
Atypical anorexia nervosa is clinically similar to anorexia nervosa. Atypical anorexia nervosa is when a person exhibits many signs that would warrant an anorexia diagnosis (such as anxiety around eating and body image) and they still are within or above a healthy weight range for their age and height, even though they may have lost a significant amount of weight. Please remember: Just because someone does not look thin or unhealthy does not mean that they couldn’t be struggling with an eating disorder such as anorexia. Due to this stigma, many people with atypical anorexia may not be aware of it since they “look normal.” This disorder can be just as debilitating as anorexia, with one study showing that adolescents with atypical anorexia were more likely to have severe eating symptoms, have lower self-esteem, and lose more weight over a longer period of time than adolescents with anorexia. Those with anorexia and atypical anorexia had similar psychiatric issues, self-harm, suicidal ideation, and medical complications (Sawyer, Whitelaw, Le Grange, Yeo, & Hughes, 2016).
Anorexia of Aging
Older adults often fail to meet their nutrient and calorie requirements. Coupled with the fact that body weight begins to decrease around age seventy, many adults face anorexia of aging, which is defined as a loss of appetite and/or decreased food intake in later life. This decreased appetite may be due to the loss of sense of smell or taste, gastrointestinal issues, decreased hormones such as ghrelin (our hunger hormone), side effects from medications, mood disorders such as anxiety and depression, or a variety of other factors. Many people assume that this is just a normal part of aging, but in reality, this is an eating disorder that should be taken seriously as it can contribute to poor nutrition and a frail body, and it can double the risk of death. Treating anorexia in the geriatric population can be a multifaceted approach depending on medications, food preferences, and other factors (Landi et al., 2016).
Nutrition-related issues, such as loss of appetite, changes in taste and smell, and early meal satiety, are common among patients with advanced cancer, particularly those with lung or gastrointestinal cancer. Cancer-related anorexia may negatively impact quality of life and may contribute to a worse cancer prognosis (Laviano, Koverech, & Seelaender, 2017). This syndrome is defined by involuntary weight loss of more than 10 percent of a patient’s body weight and may also occur among patients with AIDS, heart failure, or other serious conditions in which the body begins to waste away. Studies have shown that anamorelin and megestrol acetate, two appetite stimulants, as well as oral nutritional interventions may help improve cancer-related anorexia (Zhang, Shen, Jin, & Qiang, 2018). Patients should work with their doctor to improve their nutritional status and gain back adequate weight.
Eating a nutritious diet affects far more than what’s on the outside. Proper nutrition contributes to a healthy body, internally and externally, and is integral to wellness. Many of the health problems and mood disorders that co-occur with anorexia stem from the malnutrition itself. Treating the eating disorder is paramount so that the entire body can have the proper nutrients it needs to heal. But the most effective treatment approaches appear to be multifaceted ones that go beyond nutrition alone.
The term “intuitive eating” refers to recognizing hunger cues and satiety during meals as signals from our body for when to start and stop eating. The idea is that our body should know how much and what kind of fuel it needs. A lack of intuitive eating correlates with eating disorders. In treatment for anorexia, intuitive eating is often a goal that is worked toward, so that people can become independent, mindful eaters on their own. Many people with anorexia have disrupted hunger cues due to long periods of starvation, so their intuition may tell them not to eat or just to have one small bite of something. A pilot study found that patients at an eating disorder treatment center could develop skills for eating intuitively, and that these skills were associated with better recovery. It’s important to not create overly idealistic notions that intuitive eating will happen easily and quickly and to work slowly in the recovery process toward normalized eating patterns (Linardon & Mitchell, 2017; Richards et al., 2017).
Learning to love and appreciate your body can be a lifelong task for most of us. It’s easy to be critical and focus on what needs improvement, but research has suggested that our bodies have a “set point” where we naturally like to hang out in terms of weight, so it can take drastic measures to maintain weight loss or weight gain (Müller, Bosy-Westphal, & Heymsfield, 2010). The ultimate goal is to become grateful for the body that we have and what it enables us to do. And to learn to be kind to it with healthy food, moderate exercise, and yes, the occasional indulgence without shame or punishment. (For more on letting go of deprivation and shame, listen to The goop Podcast episode with Geneen Roth.)
Writing down what you eat and your feelings during meals in a food journal can be a helpful tool for some people with eating disorders. Clinicians may recommend that their patients use food journals in order to get an idea of what they’re eating in a regular day and to help them develop a healthier relationship with food and their associated emotions before and after meals. People with anorexia may also be encouraged to write a list of their “fear foods” that elicit a negative response and are avoided, which can help with working through emotions and developing a healthy relationship with all types of food.
That said, food journaling may be triggering for some people with eating disorders or cause them to obsess over calories and foods consumed. There are numerous food diary apps targeted at different needs, and one study found that college students with eating disorders did not necessarily choose apps that were useful or constructive for them. Work with your therapist or health care provider to determine whether a food journal is right for you (Eikey et al., 2018; Nichols and Gusella, 2003).
In the age of social media, we can easily get caught up scrolling through our phones looking at pictures of other people’s lives, including what they did today, whom they’re with, and what they’re eating. With all the fitness accounts and beauty bloggers on Instagram, our self-esteem can start to waver as we scroll, creating unrealistic expectations about what we should look like. Consuming this type of content all day can be damaging: A 2016 study found that high social media intake was associated with having increased concerns about eating (Sidani, Shensa, Hoffman, Hanmer, & Primack, 2016). This adds to previous research that has shown that increased media intake (namely, magazines) is associated with body dissatisfaction, disordered eating, and dieting among adolescent girls (Field et al., 1999; Harrison & Cantor, 1997).
Try limiting your social media intake or unfollow accounts that trigger negative feelings. And be wary of online communities for people with anorexia: While some may be helpful and encourage recovery, others—called pro-ana or simply ana communities—promote anorexia as a lifestyle choice and can be very dangerous. Be mindful about how you use social media and how it makes you feel about yourself. Parents: Consider being involved with your child’s use of the internet and have conversations with them about appropriate use of social media and online communities.
Conventional Treatment Options for Anorexia
Nutritional therapy is the first line of defense for anorexia treatment, but ideally treatments incorporate a multipronged approach.
A Multipronged Approach to Treating Anorexia
Treatment for anorexia should address both physical and psychological aspects of the illness. An interdisciplinary team of mental health, nutrition, and medical specialists should be involved in the patient’s care. Treatment is based on severity of diagnosis, individual needs, and factors that underlie or maintain the disorder, such as past trauma, family dynamics, and negative behaviors or thinking.
There are a limited number of evidence-based treatments for anorexia in adults, and relapse rates are high, so more clinical research is urgently needed in this area to better inform clinical practice and recommendations for treatment options.
Inpatient versus Outpatient Care
Treatment depends on the severity of the diagnosis. Inpatient treatment or an intensive outpatient program may be recommended. Children with anorexia may be admitted to inpatient care even sooner than adults with anorexia. Inpatient programs assist with medical stabilization and provide structure for supervision at meals and prevention of overexercising or purging. Residential programs allow for intensive care and supervision while teaching patients skills to build independence for their return home. Outpatient programs are useful for medically stable patients who don’t need as much supervision. If you’re looking for options, see goop’s guide to eating disorder treatment and recovery programs.
Nutritional Therapy for Anorexia
The American Dietetic Association sees nutritional intervention and counseling from a registered dietitian as essential for treating anorexia and other eating disorders (Ozier & Henry, 2011). The main goal of nutritional therapy is to help people gain weight because most are extremely malnourished by the time they receive treatment. Dietitians closely monitor people as calorie consumption is gradually increased throughout the weeks of treatment. Eating patterns are normalized, helping people understand hunger cues and feelings of satiety during meals. It’s important to have realistic expectations, and it’s important that dietitians work with their patients wherever they may be in their recovery process. Trying to add too much food too fast can lead to treatment dropout and complications. What is a good place to start? A small trial assessed refeeding with 500 or 1,200 calories a day, finding that higher calorie consumption led to greater weight gain and fewer associated complications (O’Connor, Nicholls, Hudson, & Singhal, 2016). Even 1,200 calories is considered a very low-calorie diet. Patients will need to gradually increase their calories over time to reach their goal.
Family-Based Treatment for Anorexia
Among children and adolescents without chronic anorexia (defined as anorexia for three or more years), the most effective therapy, according to the American Psychological Association, is family-based treatment, also referred to as the Maudsley method. This is an outpatient therapy designed to work on recovery with family support (Yager et al., 2006). Instead of blaming the family for the eating disorder, they are seen as an essential part of the treatment plan. In phase one, the parents and siblings learn how to encourage the patient to eat more. In phase two, the patient generally begins to eat more and the focus shifts to existing family dynamics that may be inhibiting recovery. In phase three, the patient should be at a normal weight and the clinician will work closely with the family to improve familial relationships and foster the patient’s independence.
Clinical studies on the use of the Maudsley method in anorexia are ongoing. For example, the Medical University of Vienna is assessing this therapy in adolescents and young adults with anorexia.
Psychotherapy and Cognitive Behavioral Therapy for Anorexia
There isn’t solid evidence on which psychological therapies are the most effective for adults with anorexia—more controlled clinical studies are urgently needed in this area to determine the gold standard treatment. It’s important for individuals with anorexia and their family members to make decisions based on individual needs for recovery and context of the illness. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are two of the most commonly used psychotherapies for anorexia.
How Is Cognitive Behavioral Therapy Used for Anorexia?
To aid with recovery and to prevent relapse, cognitive behavioral therapy addresses distorted thinking patterns, unhealthy behaviors, and emotional stress around food that people with eating disorders often struggle with. For example, someone might work through the psychological stress they feel around mealtimes by describing the feelings and thoughts that arise to their therapist. They can then begin to identify unhealthy thoughts or behaviors and work on creating healthier patterns going forward. CBT has been shown to be effective at treating depression, anxiety, low self-esteem, and obsessions, which often present alongside anorexia and other eating disorders. While CBT is widely used by health professionals in the treatment of anorexia, there is not yet robust research showing its effectiveness. A 2014 systematic review found that CBT appears to be effective and may be more effective than other psychotherapies in reducing treatment dropout, but it was not clearly superior to other treatment options (Galsworthy-Francis & Allan, 2014).
A specialized form of CBT for bulimia called CBT-BN is considered the gold standard for bulimia treatment. For anorexia treatment, a new form of CBT called enhanced CBT (CBT-E) has emerged, focused on psychological aspects of eating disorders, such as the need for control and the extreme emphasis on eating, body shape, and weight. Patients and therapists work together to identify and resolve any behaviors that help maintain the eating disorder. Although there is not yet solid evidence to support it, CBT-E is considered a promising new psychotherapy for anorexia (Dalle Grave, El Ghoch, Sartirana, & Calugi, 2016).
What Role Might Relationships Play in Eating Disorders?
Relationship and interpersonal issues can be a contributing cause or a result of eating disorders. (One psychologist we interviewed, Traci Bank Cohen, hypothesized that childhood attachment patterns may inform our relationship with food.) Unhealthy relationships or avoiding peers may be factors that maintain eating disorders and prevent recovery. And many people with anorexia develop the disorder in adolescence, which is a critical time when relationships are developed and interpersonal skills are learned. Interpersonal therapy, one of the most common psychotherapies for anorexia, works to address these complexities in three phases of therapy over four to five months. Like CBT, IPT needs more clinical research to determine how effective it is in treating anorexia (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012).
Medications for Anorexia
There is little evidence to support the use of prescription medications for anorexia. Treatments for anorexia should target both physical (weight gain) and psychological aspects of the disorder. Combining antidepressants (specifically SSRIs) with psychotherapy may help reduce depression, anxiety, or obsessive thinking and behaviors in people with anorexia, and there is some evidence that SSRIs may be helpful for preventing relapse in people who have gained back weight. Certain classes of antidepressants, such as tricyclic antidepressants and MAO inhibitors, should be avoided by those with eating disorders. The FDA has issued a black-box warning for bupropion (Wellbutrin) for patients with eating disorders as it may increase risk of seizures (Marvanova & Gramith, 2018).
Alternate Treatment Options for Anorexia
As evidence-based treatment options for anorexia are scarce, alternative treatment options deserve greater attention.
Bringing awareness to the present moment with an open, nonjudgmental perspective is the cornerstone of mindfulness. Mindfulness-based therapies are widely used for a variety of conditions—such as anxiety and depression, both of which frequently co-occur with anorexia—but have not consistently been shown to be effective for anorexia treatment. A 2017 review found that mindfulness paired with therapy or as part of a routine practice may be useful for people with anorexia, rather than shorter interventions aimed at establishing mindful eating (Dunne, 2018). Trying to eat mindfully can be challenging and even triggering for people with anorexia, so incorporating mindfulness separately from eating patterns may be most beneficial. Even though CBT techniques have comparatively more evidence showing their effectiveness than mindfulness techniques, mindfulness remains a popular treatment option (Cowdrey & Waller, 2015). There is a need for adequate research to determine the effectiveness of mindfulness therapy for anorexia.
Body Image Therapy
Negative body image predicts depression and anxiety among people with anorexia (Junne et al., 2016). A type of group CBT called body image therapy (BAT-10) incorporates aspects of mindfulness along with homework assignments and exposure to mirrors to help address these negative body perceptions and promote self-acceptance in people with anorexia. One study found that ten sessions of BAT-10 improved body-checking behaviors, body avoidance, weight concern, and anxiety in the short term (Morgan, Lazarova, Schelhase, & Saeidi, 2014). Further research is needed to validate BAT-10 and compare it to more evidence-based treatments, such as CBT.
Cognitive Remediation Therapy
A recently popularized treatment called cognitive remediation therapy (CRT) consists of various techniques to improve thinking strategies and skills to help people make behavioral changes. New research has shown that people with anorexia and other eating disorders have an altered ability to think flexibly and other signature differences in cognitive function—see the new research section for more on this. Learning new, more adaptive ways of thinking through CRT has been researched as a promising treatment (Brockmeyer, Friederich, & Schmidt, 2018). For example, CRT could focus on lessening the obsessional thinking around food at mealtimes. A 2017 meta-analysis found that CRT is potentially a good add-on treatment for children and adolescents with anorexia; further well-controlled randomized studies are needed (Tchanturia, Giombini, Leppanen, & Kinnaird, 2017).
Noninvasive brain stimulation has been recently studied as a way to regulate food cravings and food consumption by altering the neural excitability of the brain with electromagnetic pulses. The two most common types of brain stimulation that have been studied for anorexia are transcranial direct current stimulation (tDCS), which involves a weak, constant current delivered by two electrode pads placed on the head, and repetitive transcranial magnetic stimulation, in which a magnetic field is pulsed over certain brain areas. While some small studies have shown promising results for bulimia and obesity, there is not good evidence showing benefits for people with anorexia, so much more research is needed (Baumann et al., 2021; P. A. Hall, Vincent, & Burhan, 2018). There are currently two clinical trials recruiting subjects with anorexia to study tDCS, one in Minneapolis, Minnesota, and one in Saint-Étienne, France.
Stimulating the appetite is one of the major areas of new research for anorexia. This has made people wonder about marijuana—could it be used to increase hunger? Dronabinol, a cannabinoid receptor agonist drug that may promote appetite, recently became FDA-approved as a drug to treat anorexia in people with HIV and AIDS. There isn’t much research in people with anorexia yet. A small study of Danish women who had severe anorexia for five or more years found that 2.5 milligrams of dronabinol twice daily for a month induced small but significant weight gain (Andries, Frystyk, Flyvbjerg, & Stoving, 2014). While this is promising, more clinical research into dronabinol for anorexia is needed.
Gaining flexibility of the body—and the mind—is one of the main reasons people do yoga. Research has shown that yoga may also help improve anxiety and depression, which can be characteristic of eating disorder pathology. Two studies have shown that yoga improves adolescents’ eating disorder and mental health symptoms when used as an add-on to regular outpatient anorexia treatment (Carei, Fyfe-Johnson, Breuner, & Marshall, 2010; Hall, Ofei-Tenkorang, Machan, & Gordon, 2016). One possible explanation is that people with anorexia may have difficulty correctly identifying their body sensations (Khalsa et al., 2015). And yoga may help improve body awareness through deeper connection with the body during mindful yoga practice (Dittmann & Freedman, 2009).
Traditional Chinese medicine techniques that take a holistic view of health, such as acupuncture and massage, may aid in treating the emotional and physical aspects of anorexia. One study in Sydney, Australia, found that acupuncture, acupressure, and massage improved the well-being of patients with anorexia, increasing a sense of calm and relaxation (C. Smith et al., 2014). The therapeutic relationship outside of the typical medical setting as well as a sense of empathy were reported as important qualities of the treatment (Fogarty et al., 2013). Another study found that ear acupuncture in patients with severe anorexia was well accepted and increased well-being, leading to a calm state (Hedlund & Landgren, 2017). It seems that acupuncture may be a welcome alternative treatment for people with anorexia, outside of the traditional medical context.
The pace of eating is often abnormal in people with eating disorders—for example, anorexics tend to eat very little food, very slowly. To improve the eating rate and the amount of food eaten, a device called the Mandometer was developed in Sweden for people with anorexia, and it gained some traction in the 1990s. Today’s version of the device consists of an electronic scale that is connected to a smartphone app via Bluetooth. You put your plate of food on the scale and add more food until the app reads 100 percent, meaning the optimal amount of food for the meal. You then begin eating, trying to adapt your rate of eating to the reference curve that appears on the app. How full you feel is also compared to a reference scale, so that you can learn how to rate fullness more healthily. This continues until you’re finished eating (Esfandiari et al., 2018). While it’s an innovative approach, there is no solid evidence in support of the Mandometer compared to other treatments. A 2012 study in the Netherlands found that the Mandometer treatment was no better than “treatment as usual” for individuals with anorexia (van Elburg et al., 2012). But smartphone apps seem to be a promising new approach for treating a variety of mental health issues, so further research into effective internet-based therapies for anorexia would be interesting.
New and Promising Research on Anorexia
Researchers are working to discover the root causes of anorexia, while also approaching anorexia treatment with plant-based wisdom and new technology.
The Female Athlete Triad
Many adolescent girls who play sports are at risk for disordered eating, amenorrhea (lack of a period), and low bone mineral density—referred to together as the female athlete triad. With persistent exercise, girls need to maintain proper energy intake relative to the amount that they are expending. Many girls, especially those who are involved in sports where being thin can be idealized, such as ballet, figure skating, gymnastics, or running, do not consume enough calories. It’s important to catch these signs early—irregular eating or periods—before patients experience complications, such as stress fractures or osteoporosis, which can adversely impact young girls as their bodies are still developing (Kelly, Hecht, & Fitness, 2016). While there has been a wealth of research on this topic, one issue has been how to effectively apply this research to athletes to keep them safe. In 2014, the Female Athlete Triad Coalition Consensus Statement created evidence-based clinical guidelines for athletic trainers and health care practitioners. Most notably, these guidelines created risk categories that can be used to determine when a female athlete can return to play after treatment (De Souza et al., 2014).
Virtual reality (VR) has recently been used to help people with anorexia identify and evaluate cognitive biases as well as manage symptoms. In one study, women diagnosed with either anorexia or bulimia had a first-person VR jogging experience, which helped reduce their urge to compulsively exercise (Paslakis et al., 2017).
Some VR studies have tried to test the theory that people with anorexia may see themselves as heavier than they actually are. This theory was not supported by a 2018 study in which a body scan was used to create realistic virtual avatars of women with anorexia, some matching their weight and body shape and other avatars with slightly varying weights and shapes. Researchers asked the women in the study to identify which body was theirs and which body they desired. They found that the women with anorexia were fairly accurate in identifying their current weight; however, they tended to choose thinner avatars as the body they wished to have (Mölbert et al., 2018).
A recent study provided evidence that VR can be successfully used as part of a treatment program for adolescent and adult women and men with anorexia nervosa. Avatars were created for the subjects at their current weight, and then gradually over five sessions the avatars gained weight until they were at a healthy weight. Compared to a control group, those provided with this VR therapy reported significantly less fear of gaining weight and less distorted body images (Porras-Garcia et al. 2021).
Several disturbances in the way people think have been identified as characteristic of anorexia. People with anorexia tend to have increased rumination about their body weight, body shape, and food (K. E. Smith, Mason, & Lavender, 2018). There seems to be a vicious cycle of overthinking one’s body that leads to unhealthy behaviors (Sala, Vanzhula, & Levinson, 2019). Other studies have suggested that people with anorexia have unusually high fear of rejection in social situations, as well as a tendency to focus on the details in a given situation, rather than seeing the big picture (Cardi et al., 2017; Lang, Lopez, Stahl, Tchanturia, & Treasure, 2014). Identifying these biases can be useful for psychotherapy interventions, working to create new mental patterns and habits.
The Default Mode Network
The brain has connections between various structures related to self-awareness that are together referred to as the default mode network (DMN). The DMN is thought to constitute our ego and is active when people are focused internally, instead of focusing on the outside world. Researchers have investigated the DMN and the connectivity between various areas of the brain in subjects with eating disorders using fMRI. Studies have found that people with anorexia have increased connections between their DMN and areas of the brain that are associated with body image, emotions, spatial awareness, and self-image (Boehm et al., 2014; Cowdrey, Filippini, Park, Smith, & McCabe, 2014; Via et al., 2018). Which means: They tend to think more about themselves, especially how they look. But other studies have shown conflicting results, concluding that people with anorexia may actually have reduced DMN activity (McFadden, Tregellas, Shott, & Frank, 2014; Steward, Menchon, Jiménez-Murcia, Soriano-Mas, & Fernandez-Aranda, 2018). Further research into brain networks such as the DMN are needed to define the unique brain processes associated with anorexia and other eating disorders that may be useful targets in diagnosis and treatment.
THE GUT MICROBIOME
An imbalanced microbiome has been documented in people with anorexia. This could be due to preferential survival of certain species under starvation conditions. Higher than normal numbers of Methanobrevibacter smithii have been reported in the gut flora of people diagnosed with anorexia nervosa, and these bacteria may help maximize the energy people derive from food. On the other hand, one of the questions remaining is whether the unique intestinal flora helps cause anorexia. In one study, gut flora from people with anorexia nervosa were transplanted into mice, and the mice ate less and gained less weight compared to those transplanted with flora from people without an eating disorder. However, a subsequent study did not replicate these findings, so it is still not clear whether the unusual microbiota associated with anorexia is contributing to symptoms or disease progression (Reed et al., 2021).
This psychoactive plant-based tea has been traditionally used in Amazonian culture and recently has made its way into the mainstream psychedelic realm as a drink believed to transform one’s consciousness. In two recent studies, individuals diagnosed with an eating disorder reported that their experience with ceremonial ayahuasca reduced their thoughts and symptoms related to their eating disorders. Others reported reduced anxiety, depression, self-harm, and suicidal thoughts (Lafrance et al., 2017; Renelli et al., 2018). Although these were small studies of people’s reports of ayahuasca use, the findings and statements from the individuals bring hope to future research; this psychedelic could allow for greater self-love and healing from eating disorders. As one person reported, “I still have a lot of eating disorder thoughts but find there are moments where I have a lot less of them, and I think it was maybe the week after I initially did my first work [i.e., ceremony], for some reason, my brain felt like the closest it’s ever been to like feeling completely normal” (Lafrance et al., 2017).
Clinical Trials for Anorexia
Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t have access to the treatment being studied. It’s also good to understand the phase of the clinical trial: Phase 1 is the first time most drugs will be used in humans, so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments.
In general, clinical trials may yield valuable information; they may provide benefits for some subjects but have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering. To find studies that are currently recruiting for anorexia, go to clinicaltrials.gov. We’ve also outlined some below.
Float therapy is emerging in the wellness field as a spalike treatment to remove environmental stimulation. The tanks consist of water that is saturated with Epsom salt so that users float when they lie down. You float in either a darkened room or in a large pod with a lid on top to eliminate any visual stimulation. Sahib Khalsa, MD, PhD, at the Laureate Institute for Brain Research is recruiting subjects to investigate whether Floatation-REST (reduced environmental stimulation therapy) can improve anxiety in individuals with anorexia. The study is recruiting now.
Interoceptive Exposure Training
Khalsa is conducting another clinical study among patients with anorexia focused on reducing mealtime anxiety. Because people with anorexia often feel anxiety and fear before meals and this causes them to eat less, Khalsa is interested to see whether a certain type of exposure therapy can reduce this fear and improve eating behaviors. This clinical study will involve injecting patients with isoproterenol, which is an adrenaline-stimulating drug, to trigger increased heart rate and anxiety premeal so that patients can build up a tolerance and eventually reduce their fear response.
Often used for treatment of anxiety disorders, imaginal exposure therapy involves visualizing situations that elicit extreme fear, anxiety, or avoidance. In a study published in 2020, researchers at the University of Louisville provided four sessions of online imaginal exposure therapy for people with eating disorders. People worked with a therapist to identify core fears contributing to the eating disorder—for example, becoming fat—and then repeatedly visualized becoming fat in order to reduce symptoms around that fear. After completion of the therapy, people reported significantly fewer symptoms and lessened fears. However, this was a pilot study without a control group, so the findings are considered preliminary. In a follow-up clinical trial, Cheri Levinson, PhD, will continue to evaluate imaginal exposure, asking if it can prevent relapse in people recently discharged from an intensive treatment program (Levinson et al., 2020).
It’s still unclear whether certain psychological issues among people with anorexia precede malnutrition or are the result of malnutrition. Rene Stoving, MD, PhD, at the Center for Eating Disorders at Odense University Hospital is recruiting subjects with severe anorexia to study how renutrition (gaining 10 to 30 percent of their body weight) affects their psychological symptoms and cognitive function and whether these improvements last two to three months after discharge.
Rewards, Anxiety, and Relapse
Can we predict whether people who have undergone treatment for anorexia will relapse? Jamie Feusner, MD, the director of the Eating Disorder and Body Dysmorphic Disorder Research Program at UCLA, is curious about the relationship between relapse and the brain circuits that control anxiety in people with anorexia. She and her colleagues believe that anxiety diminishes the feel-good response to rewards, which means that people who stick to their recovery program wouldn’t reap the benefit of feeling good about their progress. This would lower the motivation to continue treatment and recovery programs—if it doesn’t make you feel good about yourself in some way. This clinical study will use sequential fMRI to investigate the connection between anxiety and reward in the brains of people who have completed standard eating disorder treatment. The researchers will look at how this might predict their risk of relapse in the following six months.
Benjamin Carrot, MD, at the Institut Mutualiste Montsouris in Paris is studying a new multifaceted type of family therapy called multiple family therapy (MFT). He wants to determine whether it’s a viable treatment option for increasing BMI compared to systemic family therapy (SFT). MFT combines family and group therapy into one. With MFT, several families meet together with a therapist for treatment, whereas SFT just involves the patient and their immediate family members. Patients and their families will undergo one session a month for a year, with evaluations at the end of the year and then six months after treatment ends.
If you or a loved one needs help finding support, resources, or treatment options, call the National Eating Disorders Helpline in the US at 800.931.2237.
• EatingMindfully.com provides information on mindful eating from clinical psychologist Susan Albers, who specializes in eating issues, mindfulness, and body concerns.
• The EDReferral.com provides referrals for dietitians, therapists, and doctors who specialize in eating disorder treatment.
• National Eating Disorders Association (NEDA) is a nonprofit that promotes awareness of and raises money for eating disorder prevention and cures.
• The US Department of Agriculture’s MyPlate has health and nutrition information as well as research-backed dietary guidelines.
• The Harvard T.H. Chan School of Public Health offers nutrition and healthy eating information.
• Eat, Drink, and Be Mindful by Susan Albers, PsyD, includes assessments, techniques, and exercises to address mindless eating and eating issues
• Mindful Eating 101 by Susan Albers, PsyD, is a guide to healthy eating for college students based in self-acceptance and informed choice.
• The Anorexia Workbook by Michelle Heffner, MA, and George H. Eifert, PhD, provides techniques and exercises based on acceptance and commitment therapy (ACT).
Reading on goop
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