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Anorexia Nervosa in Adolescents

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT Meet The Team >

It’s heartbreaking to see your teen become so obsessed with body weight and shape that he or she diets to the point of become dangerously thin.  Attempts to reason with or reassure your child aren’t only futile, but often result in intense power struggles that reinforce your teen’s determination to waste away to nothing.  This potentially deadly disorder – anorexia nervosa – is the disorder that ultimately led to the premature death of pop singer Karen Carpenter in the early 1980s. 

Figuring out what’s normal and what’s not when it comes to your teen’s eating habits, body image, and overall psychological health is difficult for any parent.  This brief guide is designed to help you know the signs to watch for and the steps to take if you believe your teen is battling anorexia nervosa.  

Anorexia Nervosa Statistics and Facts

Following are several statistics and facts pertaining to anorexia:

  • Of all psychiatric illnesses, anorexia nervosa has the highest mortality rate
  • Approximately 1 out of every 10 anorexia nervosa sufferers dies within 10 years after the disorder first develops
  • 4 out of every 10 adolescent females have an eating disorder
  • Although anorexia nervosa is far more frequently diagnosed in females, a significant percentage of males also develop the disorder
  • Over 6% of youth in the U.S. will develop an eating disorder at some point between the ages of 12 and 18 years
  • In today’s society, some girls as young as 6 years of age start worrying about their weight or shape
  • As many as 8 out of every 10 individuals with anorexia have battled major depression at some point
  • Compared to the general population, those who suffer from anorexia are 31 times more likely to die by suicide
  • Being unhappy with one’s body is a major factor in those who develop anorexia or bulimia
  • Anorexia nervosa impacts individuals from all walks of life

Types of Anorexia

There are two types of anorexia:

  • Restricting type – Food intake is restricted by the individual; no purging or binge-eating is involved
  • Binge eating / purging type – The individual engages in food binges and uses purging (e.g. laxatives, self-induced vomiting, etc.) to offset or “undo” the binging

Co-Occurring Disorders

Individuals with anorexia nervosa often have other co-occurring psychiatric disorders as well.  The most common disorders are:

Risk Factors

Following are several risk factors for the development of anorexia in teens:

  • Strong perfectionistic tendencies
  • Weight gain or loss – Compliments due to weight loss, as well as ridicule or hurtful remarks due to weight gain, can trigger or reinforce a teen’s focus on or obsession with being thin
  • Participation in activities with an emphasis on weight or appearance, such as dance (especially ballet), sports, modeling, acting, and other activities may lead to pressure on your teen to be very thin or lose weight, even if your teen is already at a healthy weight
  • Stressful life events – Stress can be a contributing factor in the development of anorexia. Relationship breakups, a major move, starting a new school, or the loss of a loved one are just a few examples of high-stress events
  • A family history of anorexia or other eating disorders
  • Poor coping skills
  • Low self-esteem
  • Difficulties with emotional expression

Looking for and Recognizing the Signs of Anorexia Nervosa

Eating disorders like anorexia and bulimia can be difficult to distinguish – at least in the early stages – from a relatively healthy teens’ seeming preoccupation with being thin, which is often accompanied by frequent dieting and exercising. 

Knowing what to watch for and how to recognize the symptoms of anorexia nervosa in your teen will enable you to intervene sooner than later, which is especially crucial with this potentially deadly psychiatric disorder.  Following are two of the most important things to remember:  

  • Look for and pay close attention to any changes from your teen’s normal personality or behavior, particularly pertaining to your teen’s body image and relationship with food.
  • Excessive thinness – clinically, anorexia is defined by being at a weight that is 85% or less of the individual’s ideal weight

Signs to watch for include: 

  • Unusual, rigid, or ritualistic food preparation and eating behaviors
  • Extreme fear of gaining weight or getting fat, even when thin
  • Compulsive or excessive exercise
  • Menstrual periods have become erratic or stopped entirely
  • Excessive restriction and / or monitoring of food intake
  • Dieting when thin or even emaciated
  • Constantly weighing or measuring their body
  • Often looking in the mirror to look for perceived physical flaws
  • Highly self-critical of weight, body shape, and / or appearance
  • Frequently wearing clothing that is loose or layered (to hide thinness)
  • Adamant refusal to reach or maintain a healthy weight
  • Frequently skipping meals
  • Chewing food and then spitting it out
  • Denying hunger even when hungry
  • Frequently going into the bathroom right after eating (to induce vomiting)
  • Reluctance to eat in public
  • Avoiding events or situations that include food
  • Perceiving themselves as fat even when underweight
  • Becoming less social
  • Difficulties sleeping
  • Marked changes in mood and emotions (e.g. depressed, flat, or irritable mood, feeling anxious)
  • Suicidal thoughts and behaviors*

*Suicidal thoughts or behaviors should never be ignored.  Don’t assume your teen is just being “dramatic” or manipulative.  The risk of suicide is particularly high for individuals suffering from anorexia nervosa.

Other physical signs of anorexia may include:

  • Gets cold easily
  • Thinning or breaking hair
  • Fuzzy, down-like facial hair
  • Nails crack or break easily
  • Tooth decay (due to self-induced vomiting)
  • Dry, yellowish, or flakey skin
  • Fatigue
  • Complaints of nausea, bloating, constipation
  • Bluish fingers
  • Swollen arms or legs
  • Irregular heart beat

It’s not uncommon for teens, especially females, to worry about their weight and go on a diet.  However, be careful to not assume it’s just a passing phase or that your teen is merely caught up in the latest fad.   

Knowing the First Steps to Take  

If you have reason to suspect your teen has anorexia, the first steps to take towards handling the situation are:

1Talk to your teen.  Let your child know that you are genuinely concerned regarding the behaviors you’ve been observing, that you want to help in any way you can, and that you’re there if he or she wants to talk – about anything. 

Be prepared for denial (very common with eating disorders) or a defensive response.  Avoid judgment, criticism, and shaming of any kind, as those tend to make things worse.  If your teen opens up and confirms your worst fears, strive to remain calm. 

2 – Set up an appointment for an evaluation.  Your teen’s pediatrician or your family doctor can do an initial evaluation, including a physical examination to rule out any underlying medical issues that may be causing or contributing to your teen’s disordered eating. 

With anorexia nervosa, however, it’s essential that you have your teen undergo a thorough evaluation by a psychologist or psychiatrist as soon as possible.  Look for one who not only specializes in treating children and adolescents, but who also has substantial experience in treating eating disorders. 

3 – Get your teen into treatment.  Early intervention is crucial with eating disorders, as they become increasingly difficult to successfully treat if treatment is delayed. 

Due to the complexity and seriousness of anorexia nervosa, treatment typically involves a multi-faceted approach that often includes a combination of:

  • Medical care – Ongoing medical care is necessary to monitor and address the immediate and potential health issues associated with anorexia, such as low blood pressure and electrolyte imbalances.
  • Nutritional counseling – One of the primary treatment goals for individuals with anorexia is getting back to a healthy weight. A registered dietician (RD) usually provides this component of treatment.
  • Individual psychotherapy or “talk therapy” – Psychotherapy can help your teen understand anorexia, including the underlying issues (e.g. the need for a sense of control and a severely distorted body image) that drive it and the dangerously self-destructive nature of the disorder. Some of the most effective types of psychotherapy for anorexia are:
    • Cognitive Behavioral Therapy
    • Dialectical Behavior Therapy
    • Interpersonal Therapy
  • Family therapy – Family therapy is frequently a necessary component of successful treatment for anorexia and other eating disorders. It addresses the dysfunctional family dynamics that contribute to and reinforce the teen’s disordered eating.  Family therapy can play a major role in the treatment process by teaching parents and other family members how to be supportive without enabling.
  • Medication – Currently, there are no medications specifically indicated for the treatment of anorexia nervosa. However, antidepressants and other medications may be prescribed to alleviate symptoms of depression, anxiety, and other co-occurring disorders.
  • Dual diagnosis treatment – This is indicated when there’s a co-occurring substance use disorder, and can be part of an outpatient or residential treatment program.
  • Residential treatment (see below)
  • Hospitalization (see below)

 Supporting and Encouraging Your Child 

Anorexia nervosa can be an extremely challenging disorder for your child to cope with and, hopefully, overcome.  Following are several ways you can encourage and support him or her:

  • Educate yourself about anorexia nervosa so you can have greater empathy for and understanding about what your teen is going through
  • Actively participate in your teen’s treatment
  • Be available and willing to listen to your teen
  • Use natural consequences, rather than punishment or scolding, to encourage your teen to eat. For example, if they want to drive somewhere or engage in some type of physical activity, say no.  Remind them that they’re not going to have the necessary stamina if they haven’t eaten, and it wouldn’t be safe.
  • Don’t judge or criticize what your teen is experiencing. The unusual and often extreme behaviors and irrational thinking of someone with anorexia can be baffling and often seem ridiculous to those who’ve never experienced it
  • Be patient and understanding without crossing the line into enabling (much easier said than done)
  • Pay attention to your teen’s eating behaviors, exercise habits, body image, and moods. This will help you spot the warning signs of a relapse.  It will also allow you to help your teen more effectively manage his or her eating disorder by recognizing potential triggers and patterns 
  • Strive to make family meals relaxing and enjoyable; don’t use the dinner table as a place to air grievances with each other
  • Model healthy eating and self-acceptance. If you’re frequently dieting or complaining about your own weight, you’re likely reinforcing your teen’s struggle.  Also, be careful not to criticize the weight or appearance of other people as well. 
  • Avoid getting into power struggles with your teen, especially over food and other things directly related to his or her anorexia
  • Minimize stress and over-stimulation in the home environment as much as possible, and help your teen find ways to effectively manage his or her stress
  • Spend quality time with your teen doing something he or she enjoys
  • Never minimize or shame your teen’s struggle with his or her weight, eating behaviors, or body image
  • Do your best to keep your wits about you even if you’re feeling frustrated or scared; your teen needs you for support, strength, and guidance
  • Respect your teen’s privacy and dignity; your neighbors, relatives, and friends don’t need to know about his or her eating disorder
  • Avoid nagging or lecturing your teen; if you have concerns, talk to your teen in an open, honest, and respectful manner

What to Do When Things Escalate  

The ups and downs of anorexia can be very unpredictable.  Since many individuals with anorexia also struggle with moderate to severe depression, the risk of suicidal thoughts and behaviors is quite high.  Also, because of the serious and potentially fatal damage anorexia can wreak on one’s body, health issues can easily escalate to a medical emergency if not monitored closely and addressed in a timely manner.   

If your teen is becoming increasingly depressed, actively suicidal, engaging in self-harm, physically weak, or exhibiting any type of medical distress, you must take immediate steps to ensure his or her safety and wellbeing.  A visit to the nearest ER or a brief hospital stay may be necessary to stabilize any medical issues, keep your teen safe from self-harm, and / or get serious depressive symptoms under control. 

Don’t hesitate to reach out for help.  You can:

  • Contact your child’s treatment provider asap
  • Enlist the help of a close family member or friend for support or assistance
  • Call an emergency hotline
  • Take your child to the nearest hospital emergency room (if you can do so safely) 
  • Call 911   

When Individual Therapy isn’t Enough  

Effectively treating anorexia nervosa frequently requires more than individual therapy.  Additional treatment, usually in the form of a more intensive level of treatment, may be necessary for your teen.  If he or she is:

  • Resistant to abiding by the treatment recommendations made by his or her therapist
  • Frequently sabotaging any progress made in therapy
  • Experiencing severe depression, anxiety, or other psychiatric symptoms that require a higher level of care
  • Actively suicidal – threatening or planning suicide, and / or engaging in suicide gestures or attempts
  • Developing or experiencing serious or potentially life-threatening medical problems as a result of the anorexia

then it’s time to consider a more intensive level of treatment.  This may involve:

Intensive outpatient treatment or psychiatric day treatment can vary in terms of the amount of time spent in treatment and how many times a week your teen is required to go.  These programs are often the next step up from regular outpatient treatment.

Residential treatment requires having your teen stay at a non-hospital treatment facility that specializes in treating adolescents with eating disorders and other mental health disorders.  Residential treatment typically lasts between 30 to 180 days, depending on the severity of symptoms and your child’s rate of progress.  There are many residential treatment centers throughout the country that specialize in eating disorders.

Inpatient psychiatric or medical hospitalization is the highest and most intensive level of treatment for adolescents with anorexia nervosa.  Medical staff is on hand to monitor patients 24/7, and treatment may last for a few days to several weeks.  This is usually necessary for severe or advanced cases with serious medical complications, or if there is imminent risk of suicide or self-harm.

Each of these intensive levels of treatment typically provides daily or bi-weekly visits with a psychiatrist and various types of daily therapy.

Taking Care of Yourself 

Having a teen with an eating disorder often takes a toll on the entire family.  As a parent, the very real fear of losing your child to anorexia can be extremely stressful.  The frequent power struggles and ongoing effort to understand your teen’s irrational behavior can leave you feeling exhausted and powerless.  If you don’t make it a priority to take care of yourself, you not only risk burning out; you also won’t be able to provide the guidance, emotional support, and unconditional love your teen so desperately needs. 

Things you can do to buoy yourself up during this challenging process and keep yourself grounded include:

  • Surrounding yourself with ample support from others – through a support group, therapy, friends and family, and / or church 
  • Getting sufficient rest so you have the energy to help your teen
  • Making time for yourself
  • Finding effective ways to manage your stress, such as yoga, meditation, and regular exercise

No matter how bleak things appear, don’t lose hope.  Many teens do recover and heal – both physically and emotionally – from anorexia nervosa with proper treatment and support.    

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