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Anorexia

It is common to feel conscious of your eating, but extreme dieting and weight loss can lead to an eating disorder called anorexia (or anorexia nervosa), which impacts your physical and mental health. It is thought between 1 and 4 of every 100 people will experience anorexia at some point during their lives [1]. The good news is that there are effective psychological and medical treatments for anorexia, including Cognitive Behavioral Therapy (CBT).

What is anorexia?

Anorexia is a type of eating disorder that can affect anyone. People with anorexia limit how much they eat and drink, which contributes to being a low weight. If you have anorexia, you may find that you are very concerned about controlling your food intake, your weight, and your body shape. This can make eating very distressing. Symptoms of anorexia include:

What is it like to have anorexia?

Amina struggled with anorexia. Her story illustrates what it can feel like to be affected in this way.

Amina’s difficult relationship with food

I’ve always been conscious of my body, but it wasn’t until I became unwell with glandular fever that it became a serious issue.

I was sick for around a month, during which I lost a lot of weight very quickly. When I went back to university, my friends commented on how different I looked. Knowing that I’d lost weight and that other people had noticed this felt good, so I was determined to get my weight down even further. I began making “healthy” changes to my eating, but this quickly escalated into cutting out lots of foods and then skipping meals altogether. I’d set myself a calorie limit every day and spend ages on an exercise bike at the gym. Not eating and seeing my weight go down felt like a buzz at first, but then it started taking over my life. I made excuses to not see my friends and eventually stopped going out altogether. I struggled to keep up with my coursework – I was so tired and couldn’t focus. The only things I thought about were food, exercise, and weight loss. I knew it was becoming a problem, but at the same time, I was terrified of what would happen if I ate more. Would I lose control? Would my weight shoot up? What would my friends think?

When I went home for the holidays, my parents were shocked at how much weight I’d lost. I tried to reassure them that I was ok, but they knew there was a problem. I was terrified about eating the food they made me and not being able to exercise as much at home, so we got into a lot of fights. Eventually, I agreed to talk to my family doctor about what was happening.

Understanding Anorexia Nervosa CBT Psychoeducation guide

Do I have anorexia?

Anorexia should only be diagnosed by a mental health professional or a doctor. However, answering the screening questions below can give you an idea of whether you might find it helpful to have a professional assessment.

Have you recently lost more than one stone (14lb / 6kg) in a three month period? Yes No
Would you say that food dominates your life? Yes No
Do you believe you are fat when others say you are too thin? Yes No
Do you worry that you could lose control over how much you eat? Yes No
Do you ever make yourself vomit because you feel uncomfortably full or are worried about gaining weight? Yes No
Do you limit how much you eat, or exclude certain foods, to influence your shape or weight? Yes No
Have you felt a strong desire to lose weight? Yes No
Does your weight, shape, or eating influence how you judge yourself as a person? Yes No
Have you gone for long periods without eating anything at all? Yes No
Has thinking about food, eating, or calories made it difficult to concentrate on things you are interested in (e.g., work or a conversation)? Yes No

 

If you answered ‘yes’ to many of these questions, then you might be suffering from anorexia. However, it is not always clear whether someone has an eating disorder. If you relate to any of the symptoms described above, it’s best to speak to a professional.Sometimes people worry that their difficulties aren’t serious enough or feel guilty or ashamed for struggling. It is important to remember that eating disorders can be very serious. If you are at all concerned about your eating or your weight, speak to your family doctor or a mental health professional.

What causes anorexia?

A common myth is that anorexia is caused by dieting. While diets can contribute to the development of anorexia, there is in fact no single cause. Things that may make you more likely to experience anorexia [2-4] include:

  • Your body and genes. There is some evidence that genetic and biological factors can increase your risk of developing anorexia. For example, developing anorexia is more likely when a close relative has had similar difficulties.
  • Developmental factors. During childhood, you may have developed personality traits that increase the risk of developing anorexia, such as being anxious or perfectionistic. Some research suggests that you may be at greater risk of developing anorexia if you are on the autistic spectrum, but the two are not always linked: people with anorexia do not always have autism.
  • Environmental factors. If you identify as female, you are more likely to develop anorexia than if you identify as male, though men can experience anorexia as well. Some psychologists argue that living in cultures which emphasize thinness and beauty also increases your risk of developing anorexia.
  • Psychological factors. If you have anorexia, you may hold beliefs which emphasize the need to control your shape, weight, and eating. You may also notice that you tend to think in a more fixed and detail-focused way than others. It is common to experience other mental health difficulties before or alongside anorexia, particularly anxiety-related problems such as obsessive-compulsive disorder or social anxiety.

What keeps anorexia going?

Research studies have shown that Cognitive Behavioral Therapy can help people with anorexia [5]. CBT therapists work a bit like firefighters: while the fire is burning they’re not so interested in what caused it, but are more focused on what is keeping it going, and what they can do to put it out. This is because by working out what keeps a problem going, they can treat the problem by ‘removing the fuel’ and interrupting this maintaining cycle. Some factors which psychologists think are important in keeping anorexia going are:

Treatments for anorexia

Psychological treatments for anorexia

Cognitive Behavioral Therapy (CBT) is one of several treatments with strong support for treating anorexia [6]. CBT designed for working with anorexia and other eating disorders is sometimes called ‘CBT for eating disorders’ (CBT-ED), and also includes ‘enhanced’ CBT (CBT-E) [7].CBT is a popular form of talking therapy. CBT therapists understand that what we think and the way we behave affects the way we feel. Unlike some other therapies, it is often quite structured. After talking things through to better understand your problem, you can expect your therapist to set goals with you so that you both know what you are working towards. You should seek out a therapist who has specialist training and experience in treating anorexia. At the start of most appointments, you will set an agenda together to agree what the session will concentrate on. ‘Ingredients’ of effective CBT-ED include [8, 9]:

  • Developing a shared understanding of your eating difficulties.
  • Monitoring your health and nutrition, including your weight and food intake.
  • Helping you make healthy food choices and working towards a healthy body mass index (BMI).
  • Testing your beliefs about how eating affects your weight.
  • Changing behaviors that make you more concerned about your shape and weight.
  • Building a bigger and happier life for yourself by re-engaging in activities you care about.
  • Developing new ways of managing difficult emotions that influence your eating.
  • Addressing other things that influence your self-worth.
  • Making sure that you stay healthy in the long-term.

Other treatments for anorexia nervosa

CBT is one of several evidence-based therapies recommended for treating adults with anorexia [6]. Other therapies include Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) and Supportive Clinical Management (SSCM). Focal Psychodynamic Therapy (FPT) is typically recommended as a second-line treatment if the other treatments are refused or ineffective.Sometimes psychological therapies are not sufficient to meet the needs of people with anorexia (e.g., if their physical health is severely compromised). In this situation, people may benefit from more intensive treatments (e.g., admission to a day or inpatient treatment programme). However, mental health services try to offer psychological therapy as a first-line treatment.The UK National Institute for Health and Care Excellence (NICE) recommends that medical treatments should not be offered as the sole treatment for anorexia, but can be used in conjunction with other treatments.

References

  1. Keski-Rahkonen, A., & Mustelin, L. (2016). Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors. Current Opinion in Psychiatry, 29, 340-345.
  2. Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., & Agras, W. S. (2004). Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin, 130, 19-65.
  3. Schmidt, U., & Treasure, J. (2006). Anorexia nervosa: Valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology, 45, 343-366.
  4. Zipfel, S., Giel, K. E., Bulik, C. M., Hay, P., & Schmidt, U. (2015). Anorexia nervosa: aetiology, assessment, and treatment. The Lancet Psychiatry, 2, 1099-1111.
  5. Galsworthy-Francis, L., & Allan, S. (2014). Cognitive behavioural therapy for anorexia nervosa: A systematic review. Clinical Psychology Review, 34, 54-72.
  6. National Institute for Health and Care Excellence (NICE: 2017). Eating disorders: Recognitions and treatment. Retrieved from: https://www.nice.org.uk/guidance/ng69.
  7. Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41, 509-528.
  8. Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.
  9. Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive behavioral therapy for eating disorders: A comprehensive treatment guide. Cambridge University.

About this article

This article was written by Dr Matt Pugh and reviewed by Dr Matthew Whalley, both clinical psychologists. It was last reviewed on 2021/12/08.