Shani, 15 years old and in the ninth grade, displays many symptoms of anorexia nervosa (APA, 2013). She purposely maintains a significantly low body weight, intensely fears becoming overweight, has a distorted view of her weight and shape, and is excessively influenced by her weight and shape in her self-evaluations (see Table 11-1).

Like Shani, at least half of the people with anorexia nervosa reduce their weight by restricting their intake of food, a pattern called restricting-type anorexia nervosa. First they tend to cut out sweets and fattening snacks; then, increasingly, they eliminate other foods. Eventually people with this kind of anorexia nervosa show almost no variability in diet. Others, however, lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics, and they may even engage in eating binges, a pattern called binge-eating/purging-type anorexia nervosa, which you will read about in more detail in the section on bulimia nervosa.

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Ninety to 95 percent of all cases of anorexia nervosa occur in females. Although the disorder can appear at any age, the peak age of onset is between 14 and 20 years. Between 0.5 and 4.0 percent of all females in Western countries develop the disorder in their lifetime, and many more display at least some of its symptoms (Ekern, 2014; Smink et al., 2013; Stice et al., 2013). It seems to be on the increase in North America, Europe, and Japan.

Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet (Stice & Presnell, 2010). The escalation toward anorexia nervosa may follow a stressful event such as separation of parents, a move away from home, or an experience of personal failure (Wilson et al., 2003). Although most people with the disorder recover, between 2 and 6 percent of them become so seriously ill that they die, usually from medical problems brought about by starvation, or from suicide (Suokas et al., 2013; Forcano et al., 2010).

Becoming thin is the key goal for people with anorexia nervosa, but fear provides their motivation. People with this disorder are afraid of becoming obese, of giving in to their growing desire to eat, and more generally of losing control over the size and shape of their bodies. In addition, despite their focus on thinness and the severe restrictions they may place on their food intake, people with anorexia are preoccupied with food. They may spend considerable time thinking and even reading about food and planning their limited meals (Herzig, 2004). Many report that their dreams are filled with images of food and eating (Knudson, 2006).

This preoccupation with food may in fact be a result of food deprivation rather than its cause. In a famous “starvation study” conducted in the late 1940s, 36 normal-weight conscientious objectors were put on a semistarvation diet for six months (Keys et al., 1950). Like people with anorexia nervosa, the volunteers became preoccupied with food and eating. They spent hours each day planning their small meals, talked more about food than about any other topic, studied cookbooks and recipes, mixed food in odd combinations, and dawdled over their meals. Many also had vivid dreams about food.

Persons with anorexia nervosa also think in distorted ways. They usually have a low opinion of their body shape, for example, and consider themselves unattractive (Boone et al., 2014; Siep et al., 2011). In addition, they are likely to overestimate their actual proportions. While most women in Western society overestimate their body size, the estimates of those with anorexia nervosa are particularly high. In one of her classic books on eating disorders, Hilde Bruch, a pioneer in this field, recalled the self-perceptions of a 23-year-old patient:

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This tendency to overestimate body size has been tested in the laboratory (Delinsky, 2011; Farrell, Lee, & Shafran, 2005). In a popular assessment technique, research participants look at a photograph of themselves through an adjustable lens. They are asked to adjust the lens until the image that they see matches their actual body size. The image can be made to vary from 20 percent thinner to 20 percent larger than actual appearance. In one study, more than half of the individuals with anorexia nervosa overestimated their body size, stopping the lens when the image was larger than they actually were.

The distorted thinking of anorexia nervosa also takes the form of certain maladaptive attitudes and misperceptions (Alvarenga et al., 2014; Fairburn et al., 2008). Sufferers tend to hold such beliefs as “I must be perfect in every way”; “I will become a better person if I deprive myself “; and “I can avoid guilt by not eating.”

People with anorexia nervosa also have certain psychological problems, such as depression, anxiety, low self-esteem, and insomnia or other sleep disturbances (Forsén Mantilla, Bergsten, & Birgegård, 2014; Holm-Denoma et al., 2014). A number grapple with substance abuse (Mann et al., 2014; Steiger & Israel, 2010). And many display obsessive-compulsive patterns (Degortes et al., 2014; Friederich & Herzog, 2011). They may set rigid rules for food preparation or even cut food into specific shapes. Broader obsessive-compulsive patterns are common as well. Many, for example, exercise compulsively, prioritizing exercise over most other activities in their lives (Fairburn et al., 2008). In some research, people with anorexia nervosa and others with obsessive-compulsive disorder score equally high for obsessiveness and compulsiveness. Finally, persons with anorexia nervosa tend to be perfectionistic, a characteristic that typically precedes the onset of the disorder (Boone et al., 2014).

The starvation habits of anorexia nervosa cause medical problems (Faje et al., 2014; Suokas et al., 2014; Oflaz et al., 2013). Women develop amenorrhea, the absence of menstrual cycles. Other problems include lowered body temperature, low blood pressure, body swelling, reduced bone mineral density, and slow heart rate. Metabolic and electrolyte imbalances also may occur and can lead to death by heart failure or circulatory collapse. The poor nutrition of people with anorexia nervosa may also cause skin to become rough, dry, and cracked; nails to become brittle; and hands and feet to be cold and blue. Some people lose hair from the scalp, and some grow lanugo (the fine, silky hair that covers some newborns) on their trunk, extremities, and face. Shani, the young woman whose self-description opened this chapter, recalls how her body deteriorated as her disorder was progressing:

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