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Recent advances in understanding anorexia nervosa

Guido k.w. frank.

1 Department of Psychiatry, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA

2 Neuroscience Program, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA

Megan E. Shott

Marisa c. deguzman.

Anorexia nervosa is a complex psychiatric illness associated with food restriction and high mortality. Recent brain research in adolescents and adults with anorexia nervosa has used larger sample sizes compared with earlier studies and tasks that test specific brain circuits. Those studies have produced more robust results and advanced our knowledge of underlying biological mechanisms that may contribute to the development and maintenance of anorexia nervosa. It is now recognized that malnutrition and dehydration lead to dynamic changes in brain structure across the brain, which normalize with weight restoration. Some structural alterations could be trait factors but require replication. Functional brain imaging and behavioral studies have implicated learning-related brain circuits that may contribute to food restriction in anorexia nervosa. Most notably, those circuits involve striatal, insular, and frontal cortical regions that drive learning from reward and punishment, as well as habit learning. Disturbances in those circuits may lead to a vicious cycle that hampers recovery. Other studies have started to explore the neurobiology of interoception or social interaction and whether the connectivity between brain regions is altered in anorexia nervosa. All together, these studies build upon earlier research that indicated neurotransmitter abnormalities in anorexia nervosa and help us develop models of a distinct neurobiology that underlies anorexia nervosa.

Anorexia nervosa (AN) is characterized by a persistent restriction of energy intake and leads to a body weight that is significantly lower than what is expected for height and age 1 . There is either an intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain (even though at significantly low weight). Individuals with AN experience a disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. A restricting type has been distinguished from a binge eating/purging type; individuals in the latter group may intermittently have binge eating episodes or may use self-induced vomiting to avoid weight gain. AN shows a complex interplay between neurobiological, psychological, and environmental factors 2 and is a chronic disorder with frequent relapse, high treatment costs, and severe disease burden 3 , 4 . AN has a mortality rate 12 times higher than the death rate for all causes of death for females 15 to 24 years old 5 – 7 . Treatment success is modest, and no medication has been approved for AN treatment 8 .

Various psychological or psychodynamic theories have been developed in the past to explain the causes of AN but their underlying theories have been difficult to test 9 . On the contrary, neurobiological research using techniques such as human brain imaging leads to more directly testable hypotheses and holds promise to help us tease apart mechanisms that contribute to the onset of the illness, maintenance of AN behavior, and recovery from AN. This article will review recent advances in our understanding of the neurobiology of AN. Neurobiology is a branch of the life sciences, which deals with the anatomy, physiology, and pathology of the nervous system 10 . Neurobiology is closely associated with the field of neuroscience, a branch of biology, which tries to understand brain function, from gross anatomy to neural circuits and cells that comprise them 11 . The goal of neurobiological research in AN is to develop a medical model perspective to reduce stigma and help develop better treatments 12 . At the earlier stages of brain research in AN, study samples tended to be quite small, which made replication difficult 13 . Most frequently, altered serotonin function was associated with AN and anxiety in the disorder 14 . More recent brain research has built upon those studies and increased sample sizes in structural studies and introduced studying brain function in relation to specific tasks that are thought be related to food restriction, anxiety, and body image distortion. Most studies have been carried out in adults, although there is a growing body of literature that investigated youth with AN.

The most frequently applied brain imaging study design in the past studied brain volume in AN, and more recent research now allows cortical thickness of the brain to be investigated. For a long time, there was the notion that gray matter volume and cortical thickness are lower in patients with AN (when ill and after recovery) than in controls. This research was pioneered by Katzman et al . in adolescents with AN 15 , 16 . However, recent research by Bernardoni et al . 17 and King et al . 18 in adolescents and young adults indicated that such abnormalities are rather short-lived and that both lower volume and cortical thickness normalize with weight recovery. Animal studies suggest that those changes may be due to the effects of malnutrition and dehydration on astrocytes within the brain connective tissue 19 . Two studies from our group have found larger orbitofrontal cortex and insula volume in adults and adolescents with AN after 1 to 2 weeks of normalization of food intake or in individuals after recovery, and orbitofrontal cortex volume was related to taste pleasantness 20 , 21 . Those results were intriguing as they implicated taste perception in relation to brain volume but they need replication. New data from our group in healthy first-degree relatives of patients with AN also show larger orbitofrontal cortex volume, supporting a trait abnormality (unpublished data). Studies by Bernardoni et al . in young adults have found abnormalities in gray matter gyrification in AN, and nutritional rehabilitation seems to normalize altered cortical folding 22 . A valuable lesson from those studies is that food intake can have dramatic effects on brain structure. Whether lower or higher brain volume in AN has implications on illness behavior or is instead an effect of malnutrition without effects on behavior is still unclear and needs further research 23 , 24 .

Functional brain imaging provides the opportunity to tie behavior to brain activation and thus to distinct brain neurobiology, which could become a treatment target. Several aspects of behavior in AN stand out. One is the ability to restrict food intake to the point of emaciation while the typical mechanisms to maintain a healthy body weight are inefficient. Another is how the body can maintain this behavior even when AN patients in therapy are trying to break that behavior pattern.

Relevant to food avoidance behavior is the brain reward system, which processes the motivation to eat and hedonic experience after food intake, and also calculates and updates how valuable a specific food is to us 25 . This circuitry includes the insula, which contains the primary taste cortex, the ventral striatum that comprises dopamine terminals to drive food approach, and the orbitofrontal cortex that calculates a value, while the hypothalamus integrates body signals on hunger and satiety for higher-order decision making and food approach. Many studies have used visual food cues but it has been difficult to draw conclusions on the pathophysiology of AN from those studies 26 .

Several studies from our group using sugar taste stimuli have found that brain activation in adolescent and adult AN was elevated compared with controls in response to unexpected receipt or omission of sweet taste in the insula and striatum 27 , 28 . This so-called “prediction error” response has been associated with brain dopamine circuitry and serves as a learning signal to drive approach or avoidance of salient stimuli in the environment in the future. In addition, orbitofrontal cortex prediction error response correlated positively with anxiety measures in AN 28 , 29 . We found a similar pattern of elevated brain activation in AN to unexpected receipt or omission of monetary stimuli, suggesting a food-independent alteration of brain dopamine circuitry. Importantly, those studies have also shown that brain response was predictive of weight gain during treatment and that brain dopamine function could have an important role in weight recovery in AN. This was supported by a retrospective chart review in adolescents with AN that suggested that the dopamine D 2 receptor partial agonist aripiprazole was associated with higher weight gain in a structured treatment program in comparison with patients not on that medication 30 . Mechanistically, it was hypothesized that dopamine D 2 receptor stimulation might be desensitizing those receptors and normalize behavior response. This, however, is speculative and controlled studies are lacking.

Other lines of research on the pathophysiology of AN are directed toward feedback learning, and several studies have found that AN is associated with alterations, behaviorally or in brain response. A study by Foerde and Steinglass, who investigated learning using a picture association task in patients with AN before and after weight restoration, indicated deficits in feedback learning and generalization of learned information in comparison with controls 31 . Such alterations could translate directly into difficulties in behavior modification toward recovery. Studies from Ehrlich’s group found normal feedback learning in ill, but reduced performance on reversal learning in recovered AN, which made the impact of learning in ill AN less clear 32 , 33 . Furthermore, Bernardoni et al ., using a different study design, found that individuals with AN had an increased learning rate and elevated medial frontal cortex response following punishment 34 . That result supports previous findings of elevated sensitivity to punishment in AN as a possible biological trait 35 . Another very interesting study by Foerde et al . tested brain response to food choice presenting images of food and that research implicated the dorsal striatum in this process in AN 36 . The authors also found that the strength of connectivity between striatum and frontal cortex activation correlated inversely with actual caloric food intake in a test meal after the brain scan. The authors interpreted the findings to mean that this frontostriatal involvement in AN could contribute to habit formation of food restriction behavior. Behavioral research has provided evidence that habit formation or habit strength could be necessary for the perpetuation of AN behaviors and this concept is important to study further 37 – 39 .

The self-perception of being fat despite being underweight is another aspect of AN that the field continues to struggle with in finding its underlying pathophysiology. Some studies have found a specific brain response related to altered processing of visual information or tasks that tested interoception. For instance, Kerr et al . 40 found elevated insula activation during an abdomen perception task, and Xu et al . 41 found that a frontal and cingulate cortex response during a social evaluation task correlated with body shape concerns. A study by Hagman et al ., however, indicated a strong cognitive and emotional influence on body image distortion, and the intersection between altered perception and fear-driven self-perception needs further study 42 . Social interaction and its brain biology constitute another area that was hypothesized to be related to AN behaviors and some research is emerging on this topic. For instance, a study by McAdams et al . showed that the quality of the social relationship or social reciprocity tested in a trust game showed lower occipito-parietal brain response in patients with AN in comparison with a control group 43 . This research suggests altered reward experience from interpersonal contact in AN, which could impact emotional well-being and interfere with recovery. Oxytocin, a peptide hormone related to social behavior, could play a role but this requires more detailed research 44 .

Studies on brain connectivity can test either what brain regions work in concert during a specific task (functional connectivity) or what the hierarchical organization is between areas in the brain (that is, what region drives another) (effective connectivity). Several studies in the past have shown that resting-state functional connectivity is altered in patients with AN compared with control groups. Those studies repeatedly found altered connectivity that involved the insula, a region associated with taste perception, prediction error processing, and integration of body perception, as reviewed by Gaudio et al . 45 . More recent studies found higher or lower resting-state activation in AN across various networks and during rest or task conditions 39 , 46 – 49 . Longitudinal studies will need to test what might be the best resting-state network to focus on to predict, for instance, illness outcome or whether functional connectivity during specific tasks such as taste processing could be more informative. One study by Boehm et al . found normalization of functional connectivity in the default mode but continued abnormal frontoparietal network connectivity in recovered AN 50 . It remains to be seen whether functional connectivity will normalize with recovery or can identify long-lasting or maybe trait alterations.

Effective connectivity studies indicated that while viewing fearful faces, a group with AN had deficits of brain connectivity between prefrontal cortex and the amygdala, which correlated with measures for anxiety and eating behaviors in a study by Rangaprakash et al . 51 . Studies from our group that assessed effective connectivity during the tasting of sucrose solution found that, whereas in controls the hypothalamus drove ventral striatum response, in patients with AN, effective connectivity was directed from the ventral striatum to the hypothalamus 28 , 52 . Previously, a dopamine-dependent pathway from the ventral striatum to the hypothalamus that mediates fear was described and we hypothesized that this circuitry might be activated in AN to override appetitive hypothalamic signals 53 .

In summary, brain research has started to make inroads into the pathophysiology of AN. We have learned that malnutrition has significant effects on brain structure, changes that can recover with weight restoration, but whether those alterations have an impact on illness behavior remains unclear 23 . Research into the function of brain circuits has implicated reward pathways and malnutrition-driven alterations of dopamine responsiveness together with neuroendocrine changes, and high anxiety may interfere with normal mechanisms that drive eating behavior 54 . Habit learning and associated striatal-frontal brain connectivity could provide another mechanism of how brain function and interaction of cortical and sub-cortical regions may perpetuate illness behavior that is difficult to overcome. Those advances are promising to establish that AN is associated with a distinct brain pathophysiology. This will help researchers develop effective biological treatments that improve recovery and help prevent relapse. A significant challenge to overcome will be to integrate the differing brain research studies and develop a unified model 13 . Critical in this effort will be well-powered and comparable study designs across research groups, which take into account confounding factors such as comorbidity and medication use and which use rigorous standards for data analysis.

[version 1; peer review: 2 approved]

Funding Statement

This work was supported by National Institute of Mental Health grants MH096777 and MH103436 (both to GKWF) and by T32HD041697 (University of Colorado Neuroscience Program) and National Institutes of Health/National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Awards grant TL1 TR001081 (both to MCD).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Editorial Note on the Review Process

F1000 Faculty Reviews are commissioned from members of the prestigious F1000 Faculty and are edited as a service to readers. In order to make these reviews as comprehensive and accessible as possible, the referees provide input before publication and only the final, revised version is published. The referees who approved the final version are listed with their names and affiliations but without their reports on earlier versions (any comments will already have been addressed in the published version).

The referees who approved this article are:

• Carrie J McAdams , Department of Psychiatry, University of Texas at Southwestern Medical Center, Dallas, TX, USA No competing interests were disclosed.
• Janet Treasure , Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK No competing interests were disclosed.

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Anorexia nervosa—usually just called anorexia—is a serious eating disorder. Individuals with anorexia do not eat enough and have an intense fear of being fat. Although the term anorexia nervosa means "no appetite, caused by nervousness," most people with anorexia do feel hunger but take extreme steps to ignore it, often to the point of starvation.

Anorexia usually, but not always, begins in adolescence, often as puberty starts and body shapes change.  It is more common in adolescent girls and young women but young men can also develop it.

There are two types of anorexia:

• restrictive anorexia. A person with this type limits how much food she or he takes in by eating as little as possible.
• binging and purging anorexia. Individuals with this type eat food but then vomit or use laxatives to get rid of the food.

Many individuals go back and forth between these two patterns. Individuals with anorexia also tend to exercise excessively to burn off the calories they take in.

Possible causes

Although this problem has existed for centuries, it has become more common in recent years, especially in cultures where being thin is considered attractive.

What causes anorexia isn't known. It is likely a combination of biological, psychological, and social factors such as peer and societal pressure to be thin, fear of becoming an adult, family conflicts, depression, and obsessive-compulsive tendencies.

Signs of anorexia

In the United States and other developed countries, it is common for teens to worry about their weight and appearance. But worrying about weight doesn't mean someone has an eating disorder. Individuals with anorexia take these worries to the extreme.

Possible signs of anorexia include:

• severely limiting calories, often skipping meals
• continued weight loss, or low body weight
• intense exercise
• a drive for perfection
• difficulty concentrating, making decisions, or thinking
• irritability
• depression or social withdrawal
• fainting, dizziness, lack of energy
• feeling cold when others feel warm

Diagnosing anorexia

A health professional, such as a pediatrician or a psychiatrist, can diagnose anorexia based on an individual's symptoms and whether she or he fits several specific medical and psychological criteria:

• significant weight loss, defined as more than 15% below ideal body weight
• lack of menstrual periods
• distorted body image (feeling fat in spite of being thin)
• intense fear of gaining weight or becoming fat

The health professional will also look for other signs of anorexia, such as

• low blood pressure
• enlarged salivary glands
• lanugo, a very fine type of body hair
• lack of menstrual periods in a woman
• dental problems (stomach acids from repeated vomiting can damage teeth)

Medical complications of anorexia can include stress fractures, bone loss (osteopenia), growth delay, short stature, and heart problems.

Some people with anorexia have a single, relatively brief episode. For others, the problem lasts for years. For the majority of people with anorexia, the condition fades away by late adolescence. But a significant number of people have continuing problems with diet and body image into adulthood.

Treating anorexia

Severe weight loss or starvation is a medical emergency. Early treatment is important. Individuals with severe anorexia may need to be hospitalized.

Anorexia nervosa is usually treated with a combination of psychotherapy, support, education, medication, and medical and nutritional counseling.

A general goal is to help the person achieve a minimum healthy weight. Another priority is to correct any problems with body fluids and salts.

Treatment often requires coordinating help from a number of professionals, especially in the most serious cases. Comprehensive eating disorder programs often work best because they bring together all these treatment elements.

Supportive psychotherapy and clinical management can help the person recognize her or his distorted beliefs about body image that are central to the disorder. This is a major task of treatment.

Nutritional counseling from a trained nutritionist can plan a healthy eating program that promotes slow weight gain.

Cognitive behavior therapy can help an individual recognize flawed thoughts about body image, food and dieting, and helps control anxiety about eating.

Family therapy may help identify and change negative interactions in the family, such as unproductive power struggles about food.

Medication. No medications are known to make individuals with anorexia want to eat or gain weight. Antidepressants and other medications may offer some relief for those who have symptoms of depression, anxiety, or obsessive-compulsive disorder. If an individual's thinking about food becomes distorted enough that it is considered psychotic, an antipsychotic medication such as olanzapine (Zyprexa) may help.

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Anorexia nervosa: What you need to know

Anorexia means a loss of appetite and inability to eat, often due to a physical illness. Anorexia nervosa is when a person intentionally restricts their food intake. It is part of a potentially life threatening mental health disorder that involves emotional challenges, an unrealistic body image, and an exaggerated fear of gaining weight.

A note about sex and gender

Sex and gender exist on spectrums. This article will use the terms “male,” “female,” or both to refer to sex assigned at birth. Click here to learn more .

Anorexia nervosa is the name of a mental health condition. It is a serious disease, but, with the right treatment, recovery is possible.

In some cases, an individual may lose a significant amount of weight and demonstrate the characteristic behaviors of anorexia but not have very low body weight or body mass index (BMI). Researchers refer to this as atypical anorexia nervosa.

Anorexia nervosa often appears during a person’s teenage years or early adulthood, but it can sometimes begin in the preteen years or later in life.

People often think of anorexia nervosa in connection with people who are female, but it can affect people of any sex or gender. Research suggests that the risk of eating disorders may be higher among transgender people than cisgender people.

Statistics show that females with anorexia outnumber males with the disorder at a ratio of 10 to 1. The effects of the disorder are more likely to be life threatening among males than among females. The reason for this is that males often receive a later diagnosis due to the mistaken belief that it does not affect them.

What is anorexia nervosa?

A person with anorexia nervosa will intentionally restrict their food intake as a way to lose weight or avoid gaining weight. A person with anorexia nervosa will often have an intense fear of weight gain, even if they have severely low body weight.

Dietary restrictions can lead to nutritional deficiencies, which can severely affect overall health and result in potentially life threatening complications.

The emotional and psychological challenges of anorexia nervosa can be hard for a person to overcome.

Therapy includes counseling, nutritional advice, and medical care. Some people may need treatment in the hospital.

There are many myths about eating disorders. These can lead to false assumptions and affect a person’s chances of seeking and getting help.

Learn more about the myths surrounding eating disorders and the real facts.

Anorexia nervosa symptoms

Anorexia nervosa is a complex condition. The main sign is significant weight loss or low body weight. In atypical anorexia nervosa, the person may still have a moderate weight despite substantial weight loss.

A lack of nutrients may lead to other physical signs and symptoms, including:

• severe loss of muscle mass
• listlessness, fatigue , or exhaustion
• low blood pressure
• lightheadedness or dizziness
• low body temperature with cold hands and feet or, possibly, hypothermia
• bloated or upset stomach
• swollen hands and feet
• loss of menstruation or less frequent periods
• infertility
• loss of bone density, increasing the risk of fractures
• brittle nails
• constipation
• irregular or abnormal heart rhythms
• lanugo , which is fine downy hair on the body
• increased facial hair
• bad breath and tooth decay in people who vomit frequently

The person may also demonstrate certain behaviors, such as :

• limiting their overall food intake or the range of foods they consume
• showing excessive concern with weight, body size, dieting, calories, and food
• exercising a lot, taking laxatives , or inducing vomiting
• assessing their body weight and size frequently
• talking about being “fat” or having overweight
• denying feeling hungry or avoiding mealtimes
• developing food rituals, such as eating foods in a specific order
• cooking for others without eating
• withdrawing from friends and social interaction
• showing signs of depression

The person may associate food and eating with guilt. They may seem unaware that anything is wrong or be unwilling to recognize their issues around eating.

Not everyone with the condition will behave in the same way, and some individuals may experience atypical anorexia nervosa, meaning that they will not have low body weight.

Anorexia nervosa causes

Concerns about body weight and shape are often features of anorexia nervosa, but they may not be the main cause. Experts do not know exactly why the condition occurs, but genetic, environmental, biological, and other factors may play a role.

For some people, anorexia nervosa also develops as a way of gaining control over an aspect of their life. As the person exerts control over their food intake, this feels like success, and so, the behavior continues.

Anorexia nervosa risk factors

Several factors can increase a person’s risk for developing anorexia nervosa, including :

• past criticism about their eating habits, weight, or body shape
• a history of teasing or bullying, especially about weight or body shape
• a sense of pressure from society or their profession to be slim
• low self-esteem
• having a personality that tends toward obsession or perfectionism
• sexual abuse
• a history of dieting
• pressure to fit in with cultural norms that are not their own
• historical trauma, such as racism

Biological and genetic factors

A person may also have a higher chance of developing an eating disorder if:

• a close relative has had a similar disorder
• there is a family history of depression or other mental health issues
• they have type 1 diabetes

In 2015, researchers found that people with anorexia nervosa may have different gut microbial communities than those without the condition. This could contribute to anxiety, depression, and further weight loss.

Learn how the COVID-19 pandemic has affected people with eating disorders.

Early diagnosis and prompt treatment increase the chance of a good outcome.

The doctor may ask the person questions to get an idea of their eating habits, weight, and overall mental and physical health.

They may order tests to rule out other underlying medical conditions with similar signs and symptoms, such as malabsorption, cancer, and hormonal problems.

In addition to a physical exam, this may include :

• blood tests, including coagulation tests, a complete blood count , and a comprehensive metabolic profile
• urine tests
• an electrocardiogram
• imaging tests, such as a computed tomography (CT) scan or bone density scan

A psychological evaluation is also necessary to determine if a person meets the diagnostic criteria for anorexia nervosa.

According to the National Eating Disorders Association , the criteria below can help doctors make a diagnosis. However, they note that not everyone with a serious eating disorder will meet all these criteria.

• Restriction of energy intake and significantly low body weight for the person’s age, sex, and overall health.
• Intense fear of gaining weight or becoming fat, despite being underweight .
• Changes in the way the person experiences their body weight or shape, an undue impact of body weight or shape on the person’s self-image, or denial that their current low body weight is a problem.

Anorexia nervosa vs. bulimia nervosa

Anorexia nervosa and bulimia nervosa are both eating disorders and sometimes share certain symptoms, such as an intense fear of gaining weight or a distorted body image.

However, people with anorexia often restrict food intake, exercise excessively, or adopt extreme diet patterns to lose weight.

On the other hand, bulimia nervosa is characterized by recurrent episodes of binge eating or eating large amounts of food, followed by compensatory behaviors to prevent weight gain, such as self-induced vomiting, excessive exercising, consuming laxatives, or fasting.

This cycle can also be present in people diagnosed with the binge-eating/purging subtype of anorexia nervosa.

However, unlike bulimia, anorexia nervosa is also characterized by the significant restriction of energy intake, leading to significantly low body weight for a person’s age, sex, and overall health.

Treatment and recovery

A healthcare professional will make a comprehensive plan to address the individual’s specific needs.

It will involve a team of specialists who can help the person overcome the physical, emotional, social, and psychological challenges that they face.

Strategies include:

• cognitive-behavioral therapy (CBT) , which can help the person find new ways of thinking, behaving, and managing stress
• family and individual counseling, as appropriate
• nutritional therapy, which provides information on how to use food to build and maintain health
• medication to treat depression and anxiety
• supplements to resolve nutritional deficiencies
• hospital treatment, in some cases

It can be challenging for a person with anorexia nervosa to engage in treatment. As a result, the person’s participation in therapy may fluctuate. Relapses can occur, especially during the first 2 years of treatment.

Family and friends can provide crucial support. If they can understand the condition and identify its signs and symptoms, they can support the individual during recovery and help prevent a relapse.

Hospital treatment

The person may need to spend time in the hospital if they have:

• a severely low BMI
• malnutrition
• complications due to inadequate food intake
• a persistent refusal to eat
• a psychiatric emergency

Treatment will allow for a gradual increase in food intake to restore overall health.

Complications

Complications can affect every bodily system, and they can be severe.

They include problems with:

• the cardiovascular system
• the blood, such as a low white or red blood cell count
• the digestive system
• the kidneys
• hormonal imbalances
• bone strength

Some of these issues can be life threatening. In addition to the physical effects of poor nutrition, the person may have an increased risk of suicide.

In fact, anorexia nervosa has the highest mortality rate of all mental health conditions.

For this reason, early diagnosis and treatment are essential.

Eating disorders can be caused by a variety of factors and there is currently no known way to prevent the development of anorexia nervosa.

However, recognizing the symptoms and seeking treatment early can help improve the chances of recovery.

According to the National Eating Disorders Association , prevention programs aimed at reducing factors for eating disorders could also be beneficial.

These programs typically involve changing public policy, encouraging people to question diet culture and the media, promoting body acceptance, and replacing restrictive diets with practices like intuitive eating.

Living with anorexia nervosa

Dr. Maria Rago, Ph.D., the president of the National Association of Anorexia Nervosa and Associated Disorders (ANAD) , offered Medical News Today the following tips for anyone who thinks that they or a loved one may have anorexia nervosa:

• Be kind and respectful rather than judgmental.
• Look into providers of treatment to find good matches, and meet with some of the people to decide who can best help.
• Consider a treatment team — including a dietitian, a therapist, and a psychiatrist — all of whom should specialize in eating disorders.
• Make sure to get all the education and support possible.
• Review the treatment plan and make changes when you think best.

Dr. Rago noted that ANAD has free support groups and mentoring programs for recovery and that they invite people to take advantage of the free services. “The right help can change your life, and even save your life,” she said.

Frequently asked questions

Here are a few common questions about anorexia nervosa.

What is the nervosa part of anorexia?

“Nervosa” is a term rooted in Latin that originally meant “nervous” or “vigorous.” “Anorexia” comes from both Latin and Greek and means “without appetite.”

When originally used to describe a syndrome in the Middle Ages, “anorexia” referred to a refusal to eat, with the goal of religious or spiritual purity. In the 1800s, the term “anorexia nervosa” came to mean a self-imposed food refusal.

What is the difference between anorexia and anorexia nervosa?

Anorexia is a term used to describe the loss of appetite or the inability to eat, which can be caused by many health conditions. On the other hand, anorexia nervosa is an eating disorder in which a person intentionally limits their food intake in an effort to lose weight or prevent weight gain.

What are the warning signs of anorexia?

There are many potential warning signs of anorexia, including feeling preoccupied with food, exercise, or body weight. Experiencing feelings of guilt or shame after eating, avoiding situations that involve food, and withdrawing from friends, hobbies, or activities are a few other possible warning signs.

Anorexia nervosa is an eating disorder and a serious mental health condition. It involves restricting food intake, which can lead to severe nutritional deficiencies.

The effects of anorexia nervosa can be life threatening, but counseling, medication, and treatment for underlying mental health issues can help people with this condition.

If a person has signs of anorexia nervosa, they should seek medical help. Early diagnosis and treatment are more likely to lead to a positive outcome.

Last medically reviewed on June 22, 2022

• Eating Disorders
• Nutrition / Diet
• Obesity / Weight Loss / Fitness
• Psychology / Psychiatry

How we reviewed this article:

• Anorexia nervosa. (n.d.). https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia
• Berends, T., et al. (2018). Relapse in anorexia nervosa: A systematic review and meta-analysis [Abstract]. https://pubmed.ncbi.nlm.nih.gov/30113325/
• Bulimia nervosa. (n.d.). https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia
• Cost, J., et al. (2020). Medical complications of anorexia nervosa. https://www.ccjm.org/content/87/6/361.long
• Dell'Osso, L., et al . (2016). Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive–compulsive spectrum. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939998/
• Diemer, E. W., et al. (2018). Beyond the binary: Differences in eating disorder prevalence by gender identity in a transgender sample. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5775111/
• DSM-5 changes: Implications for child serious emotional disturbance [Internet]. (2016). https://www.ncbi.nlm.nih.gov/books/NBK519712/
• Duncan, T. K., et al. (2014). Reclamation of power and self: a meta-synthesis exploring the process of recovery from anorexia nervosa. https://www.tandfonline.com/doi/full/10.1080/21662630.2014.978804
• Eating disorders. (2021). https://medlineplus.gov/eatingdisorders.html
• Edakubo, S., et al. (2020). Mortality and risk assessment for anorexia nervosa in acute-care hospitals: A nationwide administrative database analysis. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-020-2433-8
• Garber, A. K., et al. (2019). Weight loss and illness severity in adolescents with atypical anorexia nervosa. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889949/
• Kleiman, S. C., et al . (2015). The intestinal microbiota in acute anorexia nervosa and during renourishment: Relationship to depression, anxiety, and eating disorder psychopathology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4643361/
• Kouidrat, Y., et al. (2014). Eating disorders in schizophrenia: Implications for research and management. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4251071/
• Moore, C. A., et al. (2021). Anorexia nervosa. https://www.ncbi.nlm.nih.gov/books/NBK459148/
• Overview: Anorexia nervosa. (2021). https://www.nhs.uk/mental-health/conditions/anorexia/overview/
• Prevention. (n.d.). https://www.nationaleatingdisorders.org/learn/general-information/prevention
• Risk factors. (n.d.). http://www.nationaleatingdisorders.org/factors-may-contribute-eating-disorders
• Smith, A. R., et al. (2018). Eating disorders and suicidality: What we know, what we don't know, and suggestions for future research [Abstract]. https://pubmed.ncbi.nlm.nih.gov/28846874/
• Statistics & research on eating disorders. (n.d.). https://www.nationaleatingdisorders.org/statistics-research-eating-disorders
• Warning signs and symptoms. (n.d.). https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia/warning-signs-symptoms

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What is anorexia nervosa?

Types of anorexia, am i anorexic, signs and symptoms of anorexia, anorexia causes and risk factors, effects of anorexia, getting help, anorexia treatment, tip 1: understand this is not really about weight or food, tip 2: learn to tolerate your feelings, tip 3: challenge damaging mindsets, tip 4: develop a healthier relationship with food, helping someone with anorexia, anorexia nervosa: symptoms, causes, and treatment.

Are you or a loved one struggling with anorexia? Explore the warning signs, symptoms, and causes of this serious eating disorder—as well as how to get the help you need.

Anorexia nervosa is a serious eating disorder characterized by a refusal to maintain a healthy body weight, an intense fear of gaining weight, and a distorted body image. Anorexia can result in unhealthy, often dangerous weight loss. In fact, the desire to lose weight may become more important than anything else. You may even lose the ability to see yourself as you truly are.

While it is most common among adolescent women, anorexia can affect women and men of all ages. You may try to lose weight by starving yourself, exercising excessively, or using laxatives, vomiting, or other methods to purge yourself after eating. Thoughts about dieting, food, and your body may take up most of your day—leaving little time for friends, family, and other activities you used to enjoy. Life becomes a relentless pursuit of thinness and intense weight loss. But no matter how skinny you become, it’s never enough.

The intense dread of gaining weight or disgust with how your body looks, can make eating and mealtimes very stressful. And yet, food and what you can and can’t eat is practically all you can think about.

But no matter how ingrained this self-destructive pattern seems, there is hope. With treatment, self-help, and support, you can break the self-destructive hold anorexia has over you, develop a more realistic body image, and regain your health and self-confidence.

There are three types of anorexia:

• Restricting type of anorexia is where your weight loss is achieved by restricting calories (following drastic diets, fasting, exercising to excess).
• Purging type of anorexia is where your weight loss is achieved by vomiting or using laxatives and diuretics.
• Atypical anorexia is where you have all the symptoms and dangerous obsessions of anorexia, except you’re not underweight (often due to your genetic makeup). Even though you may still be in a healthy weight range, your dieting or exercise habits put severe stress on your body.

Ask yourself the following questions:

• Do you feel fat even though people tell you you're not?
• Are you terrified of gaining weight?
• Do you lie about how much you eat or hide your eating habits from others?
• Are your friends or family concerned about your weight loss, eating habits, or appearance?
• Do you diet, compulsively exercise, or purge when you're feeling overwhelmed or bad about yourself?
• Do you feel powerful or in control when you go without food, over-exercise, or purge?
• Do you base your self-worth on your weight or body size?

While people with anorexia often exhibit different habits, one constant is that living with anorexia means you're constantly hiding those habits. This can make it hard at first for friends and family to spot the warning signs. When confronted, you might try to explain away your disordered eating and wave away concerns. But as anorexia progresses, people close to you won't be able to deny their instincts that something is wrong—and neither should you. If eating and weight control your life, you don't have to wait until your symptoms have progressed or your health is dangerously poor before seeking help.

Food behavior symptoms

Dieting despite being thin. Following a severely restricted diet. Eating only certain low-calorie foods. Banning “bad” foods such as carbohydrates and fats.

Obsession with calories, fat grams, and nutrition. Reading food labels, measuring and weighing portions, keeping a food diary, reading diet books.

Pretending to eat or lying about eating. Hiding, playing with, or throwing away food to avoid eating. Making excuses to get out of meals (“I had a huge lunch” or “My stomach isn't feeling good”).

Preoccupation with food. Constantly thinking about food. Cooking for others, collecting recipes, reading food magazines, or making meal plans while eating very little.

Strange or secretive food rituals. Refusing to eat around others or in public places. Eating in rigid, ritualistic ways (e.g. cutting food “just so,” chewing food and spitting it out, using a specific plate).

Appearance and body image symptoms

Dramatic weight loss. Rapid, drastic weight loss with no medical cause.

Feeling fat, despite being underweight. You may feel overweight in general or just “too fat” in certain places, such as the stomach, hips, or thighs.

Fixation on body image. Obsessed with weight, body shape, or clothing size. Frequent weigh-ins and concern over tiny fluctuations in weight.

Harshly critical of appearance. Spending a lot of time in front of the mirror checking for flaws. There's always something to criticize. You're never thin enough.

[Read: Body Shaming: Causes, Effects, and Improving Your Body Image]

Denial that you're too thin. You may deny that your low body weight is a problem, while trying to conceal it (drinking a lot of water before being weighed, wearing baggy or oversized clothes).

Purging symptoms

Using diet pills, laxatives, or diuretics. Abusing water pills, herbal appetite suppressants, prescription stimulants, ipecac syrup, and other drugs for weight loss.

Throwing up after eating. Frequently disappearing after meals or going to the bathroom. May run the water to disguise sounds of vomiting or reappear smelling like mouthwash or mints.

Compulsive exercising. Following a punishing exercise regimen aimed at burning calories. Exercising through injuries, illness, and bad weather. Working out extra hard after bingeing or eating something “bad.”

There are no simple answers to the causes of anorexia. Anorexia is a complex condition that arises from a combination of many social, emotional, and biological factors. Although our culture's idealization of thinness plays a powerful role, there are many other contributing factors, including your family environment, emotional difficulties, low self-esteem, and traumatic experiences you may have gone through in the past.

Psychological causes . People with anorexia are often perfectionists and overachievers. They tend to be the “good” daughters and sons who do what they’re told, excel in everything they do, and focus on pleasing others. But while they may appear to have it all together, inside they feel helpless, inadequate, and worthless. Through their harshly critical lens, if they’re not perfect, they’re a total failure.

Family and social pressures . In addition to the cultural pressure to be thin, there are other family and social pressures that can contribute to anorexia. These include participation in an activity that demands slenderness, such as ballet, gymnastics, or modeling. It can also include having parents who are overly controlling, put a lot of emphasis on looks, diet themselves, or criticize their children’s bodies and appearance. Stressful life events—such as the onset of puberty, a breakup, or going away to school—can also trigger anorexia.

Biological causes . Research suggests that a genetic predisposition to anorexia may run in families. If a girl has a sibling with anorexia, she is 10 to 20 times more likely than the general population to develop anorexia herself. Brain chemistry also plays a significant role. People with anorexia tend to have high levels of cortisol, the brain hormone most related to stress, and decreased levels of serotonin and norepinephrine, which are associated with feelings of well-being.

Risk factors for anorexia

• Body dissatisfaction
• Strict dieting
• Low self-esteem
• Emotional difficulties
• Perfectionism
• Troubled family relationships
• History of physical or sexual abuse
• Other traumatic experiences
• Family history of eating disorders

While the causes of anorexia are uncertain, the physical effects are clear. When your body doesn't get the fuel it needs to function normally, it goes into starvation mode and slows down to conserve energy. Essentially, your body begins to consume itself. If self-starvation continues and more body fat is lost, medical complications pile up and your body and mind pay the price.

Source:  National Women's Health Information Center

Deciding to get help for anorexia is not an easy choice to make. It's not uncommon to feel like anorexia is part of your identity—or even your “friend.” You may think that anorexia has such a powerful hold over you that you'll never be able to overcome it. But while change is hard, it is possible.

Admit you have a problem. Up until now, you've been invested in the idea that life will improve—that you'll finally feel good—if you lose more weight. The first step in anorexia recovery is admitting that your relentless pursuit of thinness is out of your control and acknowledging the physical and emotional damage that you've suffered because of it.

Talk to someone. It can be hard to talk about what you're going through, especially if you've kept your anorexia a secret for a long time. You may be ashamed, ambivalent, or afraid. But it's important to understand that you're not alone. Find a good listener—someone who will support you as you try to heal.

Stay away from people, places, and activities that trigger your obsession with being thin. You may need to avoid looking at fashion or fitness magazines, spend less time with friends who constantly diet and talk about losing weight, and stay away from weight loss websites and “pro-ana” sites that promote anorexia.

Seek treatment from trained eating disorder professionals.

Treating anorexia involves three steps:

• Getting back to a healthy weight.
• Starting to eat more food.
• Changing how you think about yourself and food.

[Read: Eating Disorder Treatment and Recovery]

Medical treatment . The first priority in anorexia treatment is addressing and stabilizing any serious health issues. Hospitalization may be necessary if you are dangerously malnourished or so distressed that you no longer want to live. You may also need to be hospitalized until you reach a less critical weight. Outpatient treatment is an option when you’re not in immediate medical danger.

Nutritional treatment . A second component of anorexia treatment is nutritional counseling. A nutritionist or dietician will teach you about healthy eating and proper nutrition. The nutritionist will also help you develop and follow meal plans that include enough calories to reach or maintain a normal, healthy weight.

Therapy . Therapy is crucial to anorexia treatment. Its goal is to identify the negative thoughts and feelings that fuel your eating disorder and replace them with healthier, less distorted beliefs. Therapy can also help you deal with difficult emotions, relationship problems, and stress in a productive, rather than a self-destructive, way.

Along with professional treatment, the following tips can guide you on the road to recovery:

The food and weight-related issues are in fact symptoms of a deeper issue: depression, anxiety, loneliness, insecurity, pressure to be perfect, or feeling out of control. Problems that no amount of dieting or weight loss can cure.

In order to overcome anorexia, you first need to understand that it meets a need in your life. For example, maybe you feel powerless in many parts of your life, but you can control what you eat. Saying “no” to food, getting the best of hunger, and controlling the number on the scale may make you feel strong and successful—at least for a short while. You may even come to enjoy your hunger pangs as reminders of a “special talent” that most people don't possess.

Anorexia may also be a way of distracting yourself from difficult emotions. When you spend most of your time thinking about food, dieting, and weight loss, you don't have to face other problems in your life or deal with complicated emotions. Restricting food may provide an emotional numbness, anesthetizing you from feelings of anxiety, sadness, or anger, perhaps even replacing those emotions with a sense of calm or safety.

Unfortunately, any boost you get from starving yourself or shedding pounds is extremely short-lived—and at some point, it will stop working for you at all. Dieting and weight loss can't repair the negative self-image at the heart of anorexia. The only way to do that is to identify the emotional need that self-starvation fulfills and find other ways to meet it.

“I feel fat”

While your weight usually remains quite constant over the course of, say, a week, feelings of fatness can fluctuate wildly. Often, feeling fat is a mislabeling of other emotions, such as shame, boredom, frustration, or sadness. In other words, “I feel fat” really means “I feel anxious,” or “I feel lonely.” And those feelings are unlikely to ever be changed by a diet.

Identifying the underlying issues that drive your eating disorder is the first step toward recovery, but insight alone is not enough. Let's say, for example, that following restrictive food rules makes you feel safe and powerful. When you take that coping mechanism away, you will be confronted with the feelings of fear and helplessness your anorexia helped you avoid.

Reconnecting with your feelings can be extremely uncomfortable. It's why you may feel worse at the beginning of your recovery. But the answer isn't to return to the destructive eating habits you previously used to distract yourself; it's to learn how to accept and tolerate all of your feelings—even the negative ones.

Using mindfulness to cope with difficult emotions

When you start to feel overwhelmed by negativity, discomfort, or the urge to restrict food, take a moment to stop whatever you're doing and investigate what's going on inside.

Identify the emotion you're feeling. Is it guilt? Shame? Helplessness? Loneliness? Anxiety? Disappointment? Fear? Insecurity?

Accept the experience you're having. Avoidance and resistance only make negative emotions stronger. Instead, try to accept what you're feeling without judging yourself.

Dig deeper. Where do you feel the emotion in your body? What kinds of thoughts are going through your head?

Distance yourself. Realize that you are NOT your feelings. Emotions are passing events, like clouds moving across the sky. They don't define who you are.

Once you learn how to accept and tolerate your feelings, they'll no longer seem so scary. You'll realize that you're still in control and that negative emotions are only temporary. Once you stop fighting them, they'll quickly pass.

For a step-by-step guide to learning how to manage stress and uncomfortable emotions, check out HelpGuide's free Emotional Intelligence Toolkit .

New ways to find emotional fulfillment

Once you understand the link between your emotions and your disordered eating patterns—and can identify your triggers—you still need to find alternatives to dieting that you can turn to for emotional fulfillment. For example:

If you're depressed or lonely, call someone who always makes you feel better, schedule time with family or friends, watch a comedy show, or play with a dog or cat.

If you're anxious, expend your nervous energy by dancing to your favorite music, squeezing a stress ball, or taking a brisk walk or bike ride.

If you're exhausted, treat yourself with a hot cup of tea, go for a walk, take a bath, or light some scented candles.

If you're bored, read a good book, explore the outdoors, visit a museum, or turn to a hobby you enjoy (playing the guitar, knitting, shooting hoops, scrapbooking, etc.).

People with anorexia are often perfectionists and overachievers. They're the “good” daughters and sons who do what they're told, try to excel in everything they do, and focus on pleasing others. But while they may appear to have it all together, inside they feel helpless, inadequate, and worthless.

If that sounds familiar to you, here's the good news: these feelings don't reflect reality. They're fueled by irrational, self-sabotaging ways of thinking that you can learn to overcome.

Damaging mindsets that fuel anorexia

All-or-nothing thinking. Through this harshly critical lens, if you're not perfect, you're a total failure. You have a hard time seeing shades of gray, at least when it comes to yourself.

Emotional reasoning. You believe if you feel a certain way, it must be true. “I feel fat” means “I am fat.” “I feel hopeless” means you'll never get better.

Musts, must-nots, and have-tos . You hold yourself to a rigid set of rules ( “I must not eat more than x number of calories , “ “I have to get straight A's,” “ I must always be in control.” etc.) and beat yourself up if you break them.

Labeling. You call yourself names based on mistakes and perceived shortcomings. “I'm unhappy with how I look” becomes “I'm disgusting.” Slipping up becomes “I'm a “failure.”

Catastrophizing. You jump to the worst-case scenario. If you backslide in recovery, for example, you assume that there's no hope you'll ever get better.

Put your thoughts on the witness stand

Once you identify the destructive thoughts patterns that you default to, you can start to challenge them with questions such as:

• “What's the evidence that this thought is true? Not true?”
• “What would I tell a friend who had this thought?”
• “Is there another way of looking at the situation or an alternate explanation?”
• “How might I look at this situation if I didn't have anorexia?”

As you cross-examine your negative thoughts, you may be surprised at how quickly they crumble. In the process, you'll develop a more balanced perspective.

Even though anorexia isn't fundamentally about food, over time you've developed harmful food habits that can be tough to break. Developing a healthier relationship with food entails:

• Getting back to a healthy weight
• Starting to eat more food
• Changing how you think about yourself and food

Let go of rigid food rules. While following rigid rules may help you feel in control, it's a temporary illusion. The truth is that these rules are controlling you, not the other way around. In order to get better, you'll need to let go. This is a big change that will feel scary at first, but day by day, it will get easier.

Get back in touch with your body. If you have anorexia, you've learned to ignore your body's hunger and fullness signals. You may not even recognize them anymore. The goal is to get back in touch with these internal cues, so you can eat based on your physiological needs.

Allow yourself to eat all foods. Instead of putting certain food off limits, eat whatever you want, but pay attention to how you feel physically after eating different foods. Ideally, what you eat should leave you feeling satisfied and energized.

Get rid of your scale. Instead of focusing on weight as a measurement of self-worth, focus on how you feel. Make health and vitality your goal, not a number on the scale.

Develop a healthy meal plan. If you need to gain weight, a nutritionist or dietician can help you develop a healthy meal plan that includes enough calories to get you back to a normal weight. While you can do this on your own, you're probably out of touch with what a normal meal or serving size looks like.

Getting past your fear of gaining weight

Getting back to a normal weight is no easy task. The thought of gaining weight is probably extremely frightening, and you may be tempted to resist.

But this fear is a symptom of your anorexia. Reading about anorexia or talking to other people who have lived with it can help. It also helps to be honest about your feelings and fears. The better your family and treatment team understand what you're going through, the better support you'll receive.

Having anorexia can distort the way your loved one thinks—about their body, the world around them, even your motivations for trying to help. Add to that the defensiveness and denial involved in anorexia and you'll need to tread lightly.

Waving around articles about the dire effects of anorexia or declaring, “you'll die if you don't eat!” probably won't work. A better approach is to gently express your concerns and let the person know that you're available to listen. If your loved one is willing to talk, listen without judgment, no matter how out of touch the person sounds.

[Read: Helping Someone with an Eating Disorder]

Think of yourself as an “outsider.” As someone not suffering from anorexia, there isn't a lot you can do to “solve” your loved one's condition. It is ultimately their choice to decide when they are ready.

Encourage your loved one to get help. The longer an eating disorder remains undiagnosed and untreated, the harder it is on the body and the more difficult it is to overcome.

Seek advice from a health professional, even if your friend or family member won't. And you can bring others—from peers to parents—into the circle of support.

Be a role model for healthy eating, exercising, and body image. Don't make negative comments about your own body or anyone else's.

Don't act like the food police. A person with anorexia needs compassion and support, not an authority figure standing over the table with a calorie counter.

Avoid threats, scare tactics, angry outbursts, and put-downs. Anorexia is often a symptom of extreme emotional distress and develops out of an attempt to manage emotional pain, stress, and/or self-hate. Negative communication will only make it worse.

Hotlines and support

National Eating Disorders Association  or call 1-800-931-2237 (National Eating Disorders Association)

Beat Eating Disorders  or call 0345 643 1414 (Helpfinder)

Butterfly Foundation for Eating Disorders  or call 1800 33 4673 (National Eating Disorders Collaboration)

Service Provider Directory  or call 1-866-633-4220 (NEDIC)

More Information

• Almost Anorexic – Is My (or My Loved One’s) Relationship with Food a Problem? - (Harvard Health Books)
• Treatment - Tips on eating disorder treatment. (National Eating Disorders Association)
• Anorexia nervosa - FAQs on anorexia and its treatment. (Office on Women’s Health)
• Anorexia Nervosa - Includes risk factors such as body image, self esteem, and perfectionism. (Eating Disorders Victoria)
• Feeding and Eating Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. Link
• Anorexia nervosa | Office on Women’s Health. (n.d.). Retrieved July 27, 2022, from Link
• Anorexia Nervosa—Psychiatric Disorders—Merck Manuals Professional Edition. (n.d.). Retrieved July 27, 2022, from Link
• Anorexia Nervosa—StatPearls—NCBI Bookshelf. (n.d.). Retrieved July 27, 2022, from Link
• Lloyd, S., Yiend, J., Schmidt, U., & Tchanturia, K. (2014). Perfectionism in Anorexia Nervosa: Novel Performance Based Evidence. PLoS ONE, 9 (10), e111697. Link
• Moskowitz, Lindsay, and Eric Weiselberg. “Anorexia Nervosa/Atypical Anorexia Nervosa.” Current Problems in Pediatric and Adolescent Health Care 47, no. 4 (April 1, 2017): 70–84. Link
• Harrington, Brian C., Michelle Jimerson, Christina Haxton, and David C. Jimerson. “Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa.” American Family Physician 91, no. 1 (January 1, 2015): 46–52. Link
• National Eating Disorders Association. “Anorexia Nervosa,” March 31, 2023. Link
• Tozzi, Federica, Patrick F. Sullivan, Jennifer L. Fear, Jan McKenzie, and Cynthia M. Bulik. “Causes and Recovery in Anorexia Nervosa: The Patient’s Perspective.” International Journal of Eating Disorders 33, no. 2 (2003): 143–54. Link
• Woerwag-Mehta, Sabine, and Janet Treasure. “Causes of Anorexia Nervosa.” Psychiatry , Eating disorders, 7, no. 4 (April 1, 2008): 147–51. Link
• Fairburn, C. G., Z. Cooper, H. A. Doll, and S. L. Welch. “Risk Factors for Anorexia Nervosa: Three Integrated Case-Control Comparisons.” Archives of General Psychiatry 56, no. 5 (May 1999): 468–76. Link
• Zipfel, Stephan, Katrin E Giel, Cynthia M Bulik, Phillipa Hay, and Ulrike Schmidt. “Anorexia Nervosa: Aetiology, Assessment, and Treatment.” The Lancet Psychiatry 2, no. 12 (December 1, 2015): 1099–1111. Link

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