Anorexia

The fear at the heart of anorexia can feel overwhelming, and it does not go away just because someone is told they are “fine”. It can make eating feel frightening, even when the person wants to eat.

Many people with anorexia believe they are larger than they really are, even when they are very unwell. This is part of the illness, not stubbornness. Arguing about how someone looks rarely helps.

People may also deny how serious their low weight or health problems are. This can make it hard for them to accept help at first.

Some people say restricting food first gave them a sense of control when life felt chaotic or painful. Over time, the rules start to control them instead.

Perfectionism, anxiety, obsessive traits and low self-esteem are common in people who develop anorexia. Nothing ever feels “good enough”, including the body.

Therapy can help loosen these patterns, so worth is no longer measured by shape, size or achievement.

Many people with anorexia feel torn. Part of them wants to be well, and part of them is terrified of letting go of the illness. This is very common and is not a sign that someone doesn’t care.

Some therapies, like MANTRA, are built around this. They focus on what matters most to the person and on changing when they feel ready.

Many people describe anorexia as a critical voice that tells them they don’t deserve to eat, rest or be cared for. It can sound convincing because it speaks in your own words.

Families are often encouraged to separate the illness from the person: “I’m on your side, against the eating disorder.”

Some people have all the thoughts and behaviours of anorexia, but their weight is in or above the “normal” range. This is called atypical anorexia. Because they don’t look how people expect, it is often missed.

A 2016 study of teens found that those with atypical anorexia had heart and blood pressure problems about as often as teens who were underweight. Their distress about eating and body image was even stronger.

Anorexia typically starts in the mid-teens. In children and teens, it may show up as not growing or gaining weight as expected, rather than losing weight.

For under-18s, family therapy is usually the first treatment offered. Parents become part of the team.

Men make up as many as 1 in 4 people with eating disorders. Men often don’t see their symptoms as a problem, and health professionals can sometimes downplay them.

Men and women of any age can develop anorexia. Stress and painful experiences, like trauma, can play a part at any stage of life.

People of color are affected by eating disorders at similar rates to white people, but are about half as likely to be diagnosed. LGBTQ+ young people are about three times as likely to have an eating disorder as their straight peers.

An intense focus on being slim, including pressure from work or sport, is a known risk factor. Dancers, models and athletes are examples.

You might notice

• Avoiding foods they see as “fattening”
• Eating very little, or missing meals
• Making excuses not to eat with others
• Thinking or talking about food a lot, while eating little

You might notice

• Anxiety, especially around meals
• Irritability or low mood
• Pulling away from friends and things they used to enjoy
• Very high standards and harsh self-criticism

You might notice

• Dry skin or hair loss
• Feeling cold, tired, dizzy or lightheaded
• Periods stopping, or not starting in younger girls
• In children and teens, not growing as expected

Some people with anorexia exercise far more than is healthy. Exercise may feel like something they must do, even when they are tired, unwell or injured.

Anorexia can run in families. A family history of eating disorders, depression, or alcohol or drug problems raises the risk. Differences in brain chemicals like serotonin and dopamine may also play a role.

Things that can add risk

• Anxiety
• Low self-esteem
• Obsessive traits
• Perfectionism

Things that can add risk

• Being bullied
• Being criticised about eating, body shape or weight
• Emotional, physical or sexual abuse
• Trauma

Pressure from friends, culture, social media and some jobs or hobbies can push an intense focus on being slim. This is a known risk factor.

The young person and their family meet with a therapist to look at how anorexia has affected them and how the family can help. It also teaches ways to manage hard feelings and prevent relapse.

In the UK it is often around 18 to 20 sessions over a year, sometimes with group sessions alongside other families. Research suggests family-based treatment improves outcomes, especially for teens.

This therapy works on fears about weight gain, self-image and identity, and building confidence in stressful situations. It runs over many months, with some family sessions too.

CBT helps people understand the thoughts and feelings that keep anorexia going and learn new ways to cope. For adults it is often weekly for up to 40 weeks, with extra sessions at the start.

For young people, CBT is similar but includes some family sessions.

MANTRA is a therapy for adults. It focuses on what is important to the person and on changing behaviour when they feel ready. Family or carers can be involved.

In SSCM, a therapist explains how eating habits are linked to symptoms and helps the person build healthier eating over a series of weekly sessions.

A registered dietitian helps build a meal plan and regular eating, with check-ups along the way. For young people, the team also helps parents support eating at home.

Most people stay at home and go to appointments. Day programs or a hospital stay may be needed if there is a serious risk to health or safety. Care then steps back down as the person gets stronger.

Try this

1. Pick a calm, private moment, away from mealtimes.
2. Say what you’ve noticed about their mood or wellbeing, not their size.
3. Tell them what you value about them.
4. Listen more than you talk.
5. Encourage them to see a doctor or school nurse, and offer to go with them.

They may deny it or get upset. That is common. Try not to take it personally, and keep the door open.

• Arguing about food or watching every bite
• Comments on weight, shape or looks, even “You look healthy”
• Criticising or giving lots of advice
• Simple fixes like “Just eat”
• Talking about your own diet or “good” and “bad” foods

For young people, family therapy is usually the first treatment. The care team will talk with parents and carers so they can support eating at home.

What helps

• Acting early and speaking to your child’s doctor
• Keeping up fun and connection that has nothing to do with food
• Separating the illness from your child
• Staying united with other caregivers

Recovery usually takes months or longer, with good days and bad days. It is normal to feel scared, tired or frustrated.

Ideas

• Get your own counseling if you need it
• Join a group for families, such as ANAD’s free support groups
• Keep up your own sleep, meals and hobbies
• Talk to someone you trust