What is anorexia nervosa?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the following diagnostic criteria for anorexia:

• Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health
• Intense fear of gaining weight or becoming fat, even if at a significantly low weight
• Disturbance about body weight or shape, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of current low body weight

Anorexia, like all eating disorders, does not discriminate. It impacts individuals of all body sizes, both sexes, gender identities, ages, demographics, and socioeconomic statuses. Based on research estimates, the prevalence of anorexia is highest among adolescents and young adult females with the highest incidence occurring around age 15 (Van Eeden et al., 2021).

Anorexia is reported to affect between 0.9-3% of females and up to 0.3% of males over their lifetime, but these numbers are likely not accurate (Van Eeden et al., 2021).

One reason why the prevalence rates are likely not accurate is because anorexia is underdiagnosed. Anorexia is underdiagnosed among all ages, sexes and genders but some groups are more affected. This underreporting is in large part attributed to the incorrect belief that anorexia is a disease that belongs to “young, white, wealthy, cis-females”. Some of the groups that are affected by anorexia, but often go undiagnosed are:

• Males: Healthcare providers often overlook symptoms of anorexia in males, and studies often do not include male participants.
• Older adults: Although anorexia typically emerges during adolescence, recent research shows that anorexia is also prevalent among older people. While this prevalence can often be attributed to chronic, untreated anorexia, new research also finds that anorexia can emerge in adulthood. However, these patients often go undiagnosed simply because of their age.
• Minority groups: People of color and LGBTQIA+ groups are also underdiagnosed, despite being at higher risk for eating disorders due to their higher load of trauma exposure.

Several factors increase the risk of developing anorexia:

• Genetics: A family history of eating disorders or related mental health conditions may elevate the risk.
• Sociocultural influences: Societal and cultural factors can exert considerable influence, particularly on young people. Pressures to conform to unrealistic standards of beauty, thinness, and a strong emphasis on dieting and weight control in media and society contribute to the risk.
• Psychological factors: Certain personality traits and psychological characteristics, including perfectionism, low self-esteem, anxiety, and a tendency toward obsessive-compulsive behaviors, are associated with a higher risk of anorexia.
• Dieting and weight-related behaviors: Engaging in extreme dieting, rigid weight control practices, or excessive exercise with the goal of losing weight or achieving a particular body shape can increase vulnerability to anorexia. Dieting often precedes the onset of the disorder.
• Trauma or stress: Traumatic life events, such as physical or sexual abuse, can increase the risk of developing anorexia. Chronic stress, including academic, work-related, or interpersonal stressors, can also be a contributing factor.

It is important to emphasize that these risk factors often interact and can vary from person to person. Furthermore, anorexia is a complex condition, and its development typically involves a combination of biological, psychological, and environmental factors. Not everyone with these risk factors will develop anorexia, and not all individuals with anorexia will have these risk factors.

No matter who you are, the sooner you get help for anorexia, the better.

Medical risks of anorexia include:

• Cardiac complications such as a low or abnormal heart rate
• Low body temperature
• Low blood pressure
• Severe dehydration
• Kidney damage
• Muscle loss
• Hair loss
• Osteoporosis (reduction of bone density)
• Dental decay
• Gastroesophageal reflux disease
• Amenorrhea (suppression of menstrual cycle)
• Fertility issues

Anorexia is a potentially life-threatening eating disorder with the highest mortality rate of any psychiatric illness.

What is the anorexia death rate?

• Mortality rates of people with anorexia are 6-15 times higher than the general population with the highest risk being recorded in patients that required in-patient treatment (Van Eeden et al., 2021)
• People with anorexia are on average 6 times more likely to attempt suicide, although the rate is significantly higher in people with the binge/purge subtype of anorexia (Udo et al., 2019). 1 in 5 of individuals who die have committed suicide (Arcelus et al., 2011).

Anorexia is one of the most difficult eating disorders to treat successfully, both physically and psychologically. Physical recovery entails resuming and maintaining a healthy body weight and resuming menses (if lost), while psychological recovery includes adjusting thoughts and behaviors around food, exercise and body image.

Long-term studies have found that 7-9 years after an initial assessment around 30% of admitted and treated patients no longer meet the diagnostic criteria for anorexia (Herzog et al., 1999,  Eddy et al., 2017) , while 50-63% are recovered after 20-22 years of initial assessment (Löwe et al., 2001; Eddy et al., 2017). These results emphasize that for many people, anorexia lasts a long time. However, they also show that recovery is possible even after living with anorexia for many years.

Improvements can already be measured after a shorter duration of treatment. At Monte Nido & Affiliates, we have a team of researchers that continues to evaluate the success of our treatment programs.

After 6 months of residential treatment, clients at our programs have on average, 90% less eating disorder symptoms, 88% reduced depression symptoms, and 75% reductions in anxiety symptoms. After stepping down from residential treatment to day treatment, these improvements are maintained together with a continued improvement in weight restoration.

No matter where you are at in your journey, recovery from anorexia is possible.

Researchers continue to work to identify what factors best predict disease progress and treatment outcome. Below are a number of factors that researchers most commonly report to influence treatment and disease course:

• Comorbid diseases: Increased number of comorbid disorders increases the risk of longer disease duration, increased mortality risk and reduced treatment response (Miskovic-Wheatley et al., 2023).
• Age of diagnosis: Earlier age of diagnosis and longer hospital stay during first hospitalization have been associated with better outcomes (Papadopoulos et al., 2021; Errichiello et al., 2016), while other studies have found that earlier diagnosis was associated with chronicity of the disease and poorer outcome (Meule et al., 2023). Some studies find that older age at start of treatment predicts poorer outcomes (Pike, 1998).
• Trauma: Trauma increases the risk of developing anorexia and other eating disorders, while also reducing treatment success (Day et al., 2023). At Monte Nido & Affiliates, 45% of adults admitted for residential treatment meet criteria for posttraumatic stress disorder (PTSD). Researchers have found that people with concurrent eating disorders and PTSD have improved outcomes with trauma informed care. At Monte Nido & Affiliates, we implement evidence-based trauma treatment called cognitive processing therapy (CPT), which we recently demonstrated to significantly improve treatment success in people with eating disorders and PTSD.