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Anorexia Nervosa

How Instagram led to two teens' eating disorders

Story by Sara Sidner and Julia Jones, CNN and The Oregon Herald

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Published on October 10, 2021 1:04 AM
Experts consider anorexia nervosa to be the most deadly of all mental illnesses because it has the highest mortality rate. For this reason, we can consider it to be the most severe of the 12 types of eating disorders. This condition involves severe food-restriction and sometimes extreme exercising and other purging behaviors.
At 14, Ashlee Thomas was in the grips of anorexia.

She weighed 85 pounds. She was hospitalized. Her heart stopped twice. Doctors thought she would not survive. But she did. And now the resident of New South Wales, Australia, is dedicating her life to helping other girls. Her first warning to parents and children is about the dangers of Instagram, where, Thomas says, her journey to a near death began.

On the app Thomas started following "clean eating" influencers. She was an athlete looking to have the most fit body she could create. And the bodies she considered ideal streamed down her timeline every single day, with every "like" and comment enticing her to emulate the types of bodies she saw. "I just wanted to be liked and loved like they were," said Thomas, now 20.

"I wanted to get a taste of that." But the opposite happened. She began to hate herself.

One commenter reacted to photos Thomas posted of herself by writing that her stomach was fat. At some point she stopped eating. She said her parents tried everything to get her to eat. Child welfare authorities were called on them as they resorted to force feeding her.

"It got to the stage where I remember sitting down and my dad holding my jaw open and my mom syringing food into my mouth because I just refused to eat," Thomas recalled...

The 12 Types of Eating Disorders

1. Anorexia Nervosa
Experts consider anorexia nervosa to be the most deadly of all mental illnesses because it has the highest mortality rate. For this reason, we can consider it to be the most severe of the 12 types of eating disorders. This condition involves severe food-restriction and sometimes extreme exercising and other purging behaviors. The individual will typically show these signs and symptoms:
Intense fear of gaining weight, even small amounts are intolerable. Losing weight rapidly and consistently staying underweight. Their skinny appearance can be alarming for friends and family. Refusal to acknowledge that such a low body weight can have harmful health consequences. Amenorrhea: this is a term for when women stop menstruating due to low-fat content. Heart damage: anorexia stresses the cardiovascular system and can lead to a variety of life-threatening heart conditions.

2. Bulimia Nervosa
This condition, bulimia nervosa, occurs when someone is repeatedly binging on large amounts of food and then purging it. Purging behaviors include forcing oneself to throw up, over-exercising, and using diet pills and laxatives. Both binging and purging behaviors are dangerous, and together they can quickly lead to dangerous physical symptoms.

3. Muscle Dysmorphia
Unlike most types of eating disorders, muscle dysmorphia tends to affect more men than women. The disorder is characterized by a disruptive obsession with musculature and physique. The individual will fixate on obtaining the "perfect' form of musculature.

4. Binge Eating Disorder (BED)
BED is characterized by episodes of binging on large amounts of food. A binge describes when someone consumes an excessive amount of food within a period of two hours. Binges are accompanied by a trance-like state, feeling guilty and ashamed afterward, and weight gain. Unlike bulimia, BED does not usually include any purging behaviors. Typically, those affected by BED are overweight or obese because of the binging.

5. Other Specified Feeding or Eating Disorder (OSFED) OSFED is a "catch-all" for types of eating disorders that don't fit into the above categories. Doctors and psychologists will often diagnose those with atypical anorexia or bulimia, as well as the following 7 unofficial diagnoses, with OSFED.

6. Compulsive Over Eating (COE)
This disorder is similar to binge eating disorder. What makes COE unique is that the individual doesn't binge in spurts, but rather eats large amounts of food all day long.

7. Prader Willi Syndrome
This syndrome, which leads to compulsive eating and obesity, is caused by an inherited genetic disease. It begins with weak muscles, poor feeding, and slow development in babies. Then, in childhood, the disease causes insatiable hunger. Children with Prader Willi Syndrome often develop diabetes and struggle to adapt to a normal lifestyle.

8. Diabulimia
This occurs when someone who is diabetic uses their prescription insulin to try to induce weight loss.

9. Orthorexia Nervosa (a term coined by the writer and medical doctor, Steven Bratman) We are all under pressure to eat healthier for various reasons. In the case of orthorexia nervosa, someone becomes so obsessed with planning a perfect diet that it disrupts their life.

10. Selective Eating Disorder
This eating disorder is a bit like picky eating, but at an extreme, debilitating level. An individual is so selective about their food, usually sticking to a one or two meals, that they become sick.

11. Drunkorexia
With a slightly crass sounding name, this term describes an eating disorder that is accompanied by alcoholism as well. The drunkorexic individual restricts food and purges in order to "save calories" for drinking alcohol. Severe malnutrition can develop when drunkorexia goes untreated.

12. Pregorexia
Since it is fairly common knowledge that pregnancy leads to weight gain and other bodily changes, so most women go into pregnancy with a weight loss plan. Sometimes, the weight loss plan can be too extreme and can endanger both mom and baby. Pregorexia can lead to low birth weight, coronary heart disease, type 2 diabetes, stroke, hypertension, cardiovascular disease risk, and depression.

Eating disorders have the highest mortality rate of any psychiatric disorder. Now mental health researchers in Denmark have found evidence that people with anorexia nervosa have an enhanced sense of smell. The findings, published in the open-access journal PLOS One, could lead to a new avenue of treatment for the potentially deadly illness.

Anorexia is characterized by body image distortion and extremely low body weight. The new research suggests that olfactory sensitivity — meaning a heightened sense of smell — plays a role in the disorder.

"The interest in olfaction and anorexia nervosa began with the intention to understand why it is so difficult to recover from this disorder in some, but not all, cases. My colleagues and I decided to study social functioning in persons with anorexia nervosa, along with areas that might relate to social functioning," explained the study's corresponding author, Mette Bentz of the Mental Health Services in the Capital Region of Denmark and the University of Copenhagen.

Types of Treatment for Eating Disorders:
"I wake up. I feel my thighs and my pelvic bones to see if they rise above my stomach slightly, but they don't - not enough. I'm already disappointed in myself. Getting on the scale this morning will set my mood for the day. The number on the scale is a direct reflection of my happiness. It will determine everything that follows in my relationship with food and how I feel about myself."

Skinny woman having stress about weight loss It can be difficult to find the right type of treatment for eating disorders. It is important that the eating disorder treatment program has a full staff dedicated to eating disorder treatment that would include a medical doctor, eating disorder therapists, eating disorder registered dietitians, and support staff that understand and support the eating disorder program and most importantly the client.

Each type of treatment for eating disorders requires the program to consider what the client is struggling with in their relationship with food, weight and body image, in addition to the potential medical consequences that can accompany the specific type of eating disorder. This way the entire team can support each client's individual recovery with optimum care.

Breathe Life Healing Centers addresses the types of treatment for eating disorders from this perspective. No one person is the same. Our treatment for eating disorders focuses on supporting and understand each person's clinical, emotional, and medical needs. Our Medical Director is a regarded expert in treating eating disorders, as well as our eating disorder dietitians, eating disorder therapists and staff.

Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Anorexia is a term of Greek origin: an- and orexis , translating literally to 'a loss of appetite'; the adjective nervosa indicating the functional and non-organic nature of the disorder. Anorexia nervosa was coined by Gull in 1873 but, despite literal translation, the symptom of hunger is frequently present and the pathological control of this instinct is a source of satisfaction for the patients. Patients with anorexia nervosa commonly see themselves as overweight, although they are in fact underweight. The DSM-5 describes this perceptual symptom as 'disturbance in the way in which one's body weight or shape is experienced'. In research and clinical settings, this symptom is called 'body image disturbance'. Patients with anorexia nervosa also often deny that they have a problem with low weight. They may weigh themselves frequently, eat small amounts, and only eat certain foods. Some exercise excessively, force themselves to vomit , or use laxatives to lose weight and control body shapes. Medical complications may include osteoporosis, infertility, and heart damage, among others. Women will often stop having menstrual periods. In extreme cases, patients with anorexia nervosa who continually refuse significant dietary intake and weight restoration interventions, and are declared incompetent to make decisions by a psychiatrist, may be fed by force under restraint via nasogastric tube after asking their parents or proxies to make the decision for them.

The cause of anorexia is currently unknown. There appear to be some genetic components with identical twins more often affected than fraternal twins. Cultural factors also appear to play a role, with societies that value thinness having higher rates of the disease. Additionally, it occurs more commonly among those involved in activities that value thinness, such as high-level athletics, modeling, and dancing. Anorexia often begins following a major life-change or stress-inducing event. The diagnosis requires a significantly low weight and the severity of disease is based on body mass index in adults with mild disease having a BMI of greater than 17, moderate a BMI of 16 to 17, severe a BMI of 15 to 16, and extreme a BMI less than 15. In children, a BMI for age percentile of less than the 5th percentile is often used.

Treatment of anorexia involves restoring the patient back to a healthy weight, treating their underlying psychological problems, and addressing behaviors that promote the problem. While medications do not help with weight gain, they may be used to help with associated anxiety or depression. Different therapy methods may be useful, such as cognitive behavioral therapy or an approach where parents assume responsibility for feeding their child, known as Maudsley family therapy. Sometimes people require admission to a hospital to restore weight. Evidence for benefit from nasogastric tube feeding is unclear; such an intervention may be highly distressing for both anorexia patients and healthcare staff when administered against the patient's will under restraint. Some people with anorexia will have a single episode and recover while others may have recurring episodes over years. Many complications improve or resolve with the regaining of weight.

Globally, anorexia is estimated to affect 2.9 million people as of 2015. It is estimated to occur in 0.9% to 4.3% of women and 0.2% to 0.3% of men in Western countries at some point in their life. About 0.4% of young women are affected in a given year and it is estimated to occur ten times more commonly among women than men. Rates in most of the developing world are unclear. Often it begins during the teen years or young adulthood. While anorexia became more commonly diagnosed during the 20th century it is unclear if this was due to an increase in its frequency or simply better diagnosis. In 2013, it directly resulted in about 600 deaths globally, up from 400 deaths in 1990. Eating disorders also increase a person's risk of death from a wide range of other causes, including suicide. About 5% of people with anorexia die from complications over a ten-year period, a nearly six times increased risk. The term 'anorexia nervosa' was first used in 1873 by William Gull to describe this condition.

In recent years, evolutionary psychiatry as an emerging scientific discipline has been studying mental disorders from an evolutionary perspective. It is still debated whether eating disorders such as anorexia have evolutionary functions or if they are problems resulting from a modern lifestyle.

This disorder is characterized by attempts to lose weight to the point of starvation. A person with anorexia nervosa may exhibit a number of signs and symptoms, the type and severity of which may vary and be present but not readily apparent.

Anorexia nervosa, and the associated malnutrition that results from self-imposed starvation, can cause complications in every major organ system in the body. Hypokalaemia, a drop in the level of potassium in the blood, is a sign of anorexia nervosa. A significant drop in potassium can cause abnormal heart rhythms, constipation, fatigue, muscle damage, and paralysis.

Signs and symptoms may be classified in physical, cognitive, affective, behavioral and perceptual:

Physical symptoms

Cognitive symptoms

  • An obsession with counting calories and monitoring fat contents of food.
  • Preoccupation with food, recipes, or cooking; may cook elaborate dinners for others, but not eat the food themselves or consume a very small portion.
  • Admiration of thinner people.
  • Thoughts of being fat or not thin enough
  • An altered mental representation of one's body
  • Difficulty in abstract thinking and problem solving
  • Rigid and inflexible thinking
  • Poor self-esteem
  • Hypercriticism and clinical perfectionism

Affective symptoms

Behavioral symptoms

  • Food restrictions despite being underweight or at a healthy weight.
  • Food rituals, such as cutting food into tiny pieces, refusing to eat around others, and hiding or discarding of food.
  • Purging (only in the anorexia purging subtype) with laxativesdiet pillsipecac syrup, or water pills to flush food out of their system after eating or engage in self-induced vomiting.
  • Excessive exercise, including micro-exercising, for example making small persistent movements of fingers or toes.
  • Self harming or self-loathing.
  • Solitude: may avoid friends and family and become more withdrawn and secretive.

Perceptual symptoms

  • Perception of self as overweight, in contradiction to an underweight reality (namely "body image disturbance"
  • Intolerance to cold and frequent complaints of being cold; body temperature may lower (hypothermia) in an effort to conserve energy due to malnutrition.
  • Altered body schema (i.e. an implicit representation of the body evoked by acting)
  • Altered interoception

Treatment There is no conclusive evidence that any particular treatment for anorexia nervosa works better than others. Treatment for anorexia nervosa tries to address three main areas. Treating the psychological disorders related to the illness; Reducing or eliminating behaviors or thoughts that originally led to the disordered eating. In some clinical settings a specific body image intervention is performed to reduce body dissatisfaction and body image disturbance. Although restoring the person's weight is the primary task at hand, optimal treatment also includes and monitors behavioral change in the individual as well. There is some evidence that hospitalization might adversely affect long term outcome, but sometimes is necessary. Psychotherapy for individuals with AN is challenging as they may value being thin and may seek to maintain control and resist change. Initially, developing a desire to change is fundamental. Despite no evidence for better treatment in adults patients, research stated that family based therapy is the primary choice for adolescents with AN.

Family-based treatment has been shown to be more successful than individual therapy for adolescents with AN. Various forms of family-based treatment have been proven to work in the treatment of adolescent AN including conjoint family therapy , in which the parents and child are seen together by the same therapist, and separated family therapy in which the parents and child attend therapy separately with different therapists. Proponents of family therapy for adolescents with AN assert that it is important to include parents in the adolescent's treatment.

A four- to five-year follow up study of the Maudsley family therapy, an evidence-based manualized model, showed full recovery at rates up to 90%. Although this model is recommended by the NIMH, critics claim that it has the potential to create power struggles in an intimate relationship and may disrupt equal partnerships. Cognitive behavioral therapy is useful in adolescents and adults with anorexia nervosa. One of the most known psychotherapy in the field is CBT-E, an enhanced cognitive-behavior therapy specifically focus to eating disorder psychopatology. Acceptance and commitment therapy is a third-wave cognitive-behavioral therapy which has shown promise in the treatment of AN. Cognitive remediation therapy is also used in treating anorexia nervosa. Schema-Focused Therapy was developed by Dr. Jeffrey Young and is effective in helping patients identify origins and triggers for disordered eating.

Diet is the most essential factor to work on in people with anorexia nervosa, and must be tailored to each person's needs. Food variety is important when establishing meal plans as well as foods that are higher in energy density. People must consume adequate calories, starting slowly, and increasing at a measured pace. Evidence of a role for zinc supplementation during refeeding is unclear.

Medication Pharmaceuticals have limited benefit for anorexia itself. There is a lack of good information from which to make recommendations concerning the effectiveness of antidepressants in treating anorexia. Administration of olanzapine has been shown to result in a modest but statistically significant increase in body weight of anorexia nervosa patients.

Admission to hospital AN has a high mortality and patients admitted in a severely ill state to medical units are at particularly high risk. Diagnosis can be challenging, risk assessment may not be performed accurately, consent and the need for compulsion may not be assessed appropriately, refeeding syndrome may be missed or poorly treated and the behavioural and family problems in AN may be missed or poorly managed. Guidelines published by the Royal College of Psychiatrists recommend that medical and psychiatric experts work together in managing severely ill people with AN.

Refeeding syndrome The rate of refeeding can be difficult to establish, because the fear of refeeding syndrome can lead to underfeeding. It is thought that RFS, with falling phosphate and potassium levels, is more likely to occur when BMI is very low, and when medical comorbidities such as infection or cardiac failure, are present. In those circumstances, it is recommended to start refeeding slowly but to build up rapidly as long as RFS does not occur. Recommendations on energy requirements vary, from 5–10 kcal/kg/day in the most medically compromised patients, who appear to have the highest risk of RFS, to 1900 kcal/day.


AN has the highest mortality rate of any psychological disorder. The mortality rate is 11 to 12 times greater than in the general population, and the suicide risk is 56 times higher. Half of women with AN achieve a full recovery, while an additional 20–30% may partially recover. Not all people with anorexia recover completely: about 20% develop anorexia nervosa as a chronic disorder. If anorexia nervosa is not treated, serious complications such as heart conditions and kidney failure can arise and eventually lead to death. The average number of years from onset to remission of AN is seven for women and three for men. After ten to fifteen years, 70% of people no longer meet the diagnostic criteria, but many still continue to have eating-related problems.

Alexithymia influences treatment outcome. Recovery is also viewed on a spectrum rather than black and white. According to the Morgan-Russell criteria, individuals can have a good, intermediate, or poor outcome. Even when a person is classified as having a 'good' outcome, weight only has to be within 15% of average, and normal menstruation must be present in females. The good outcome also excludes psychological health. Recovery for people with anorexia nervosa is undeniably positive, but recovery does not mean a return to normal.

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