An eating disorder is any disorder characterized primarily by a pathological disturbance of

attitudes and behaviors related to food, including anorexia nervosa, bulimia nervosa, and

binge-eating disorder. Other eating-related disorders include pica and rumination, which are

usually diagnosed in infancy or early childhood (American psychiatric association, 2018).

Eating disorders are defined as severe disturbances in eating characterised by: 1) weight

concerns, 2) body dissatisfaction, and 3) eating problems that are more extreme than the norm

causing the individual significant distress and dysfunction.

The term anorexia nervosa literally means “lack of appetite induced by nervousness.”

Anorexia nervosa is a severe eating disorder characterized by an intense fear of gaining

weight, a distorted body image, and restrictive eating behaviors that lead to extreme weight

loss. Individuals with anorexia may engage in behaviors such as excessive exercise, extreme

dieting, or purging to maintain a low body weight. It commonly begins during adolescence or

early adulthood, though cases can emerge outside these age ranges. This disorder is

associated with significant physical and psychological consequences, including malnutrition,

organ damage, and increased risk of suicide (American psychiatric association, 2018).

Diagnostic criteria of anorexia disorder according to Diagnostic and Statistical Manual of

Mental Disorders, Fifth Edition, Text Revision.

A. Restriction of energy intake relative to requirements, leading to a significantly low

body weight in the context of age, sex, developmental trajectory, and physical health.

Significantly low weight is defined as a weight that is less than minimally normal or, for

children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes

with weight gain, even though at a significantly low weight.

 C. Disturbance in the way in which one’s body weight or shape is experienced, undue

influence of body weight or shape on self-evaluation, or persistent lack of recognition of the

seriousness of the current low body weight.

Now we will try to understand the diagnostic features of anorexia nervosa with the help of

a case study. Julie, a 17-year-old high school student, presented with significant weight loss

and health complications when she first sought help. Her physical appearance was emaciated,

with sunken eyes, pasty skin, and a body weight of 75 pounds. Eighteen months earlier, Julie

had been overweight, weighing 140 pounds at 5 feet 1 inch. Her rapid weight loss, obsessive

behaviors, and medical symptoms provided a classic presentation of anorexia nervosa,

characterized by restrictive eating, intense fear of weight gain, and distorted self-perception.

Julie’s journey into anorexia nervosa began with external pressures regarding her weight and

appearance. Her mother, described as overbearing and demanding, often nagged Julie about

her size. Although her friends were kinder, they also implied that weight loss could improve

her social life and increase her chances of dating. These social influences sparked Julie’s

determination to lose weight, and she embarked on a strict diet.

Initially, Julie experienced feelings of control and accomplishment as the weight began to

drop. Positive reinforcement from friends and family further fueled her efforts, creating a

cycle of external validation and internal satisfaction.

Persistent energy intake restriction (Criterion A). Julie exhibited extreme caloric

restriction, resulting in a significant weight loss that placed her well below the minimally

normal weight for her age, sex, and developmental stage. Her cessation of menstruation

(amenorrhea) indicated her body was under severe nutritional stress. Despite these changes,

Julie continued to restrict her intake and believed she could lose more weight.
 Intense fear of gaining weight (Criterion B). Although Julie acknowledged she

"probably should put on a little weight," her actions and beliefs contradicted this statement.

She expressed no genuine concern about her low weight and continued to exercise

excessively, often in secret, to counteract the calories consumed during meals.

Disturbance in self-perceived weight or shape (Criterion C). Julie believed she looked

"fine" and even thought she could stand to lose more weight. Her self-esteem became

intertwined with her weight loss, and she interpreted dieting and exercising as markers of

control and success. This distorted self-perception persisted despite her family’s growing

concern and her visible malnourishment.

Julie’s case highlights the severe consequences of anorexia nervosa, including physical,

psychological, and social impacts:

Physical Symptoms. Julie’s malnutrition led to the development of left lower leg

numbness and a left foot drop due to peroneal nerve paralysis, a condition associated with

inadequate nutrition. Her skin appeared pasty, and she exhibited signs of bradycardia and

hypotension, commonly seen in individuals with starvation.

Psychological Symptoms. Julie reported a “loss of taste for food,” although research

suggests individuals with anorexia often crave food but suppress these cravings. Her

obsessive exercising and inability to recognize the severity of her condition reflect the

cognitive distortions characteristic of the disorder.

Behavioral Patterns. Julie’s compulsive exercise became a significant aspect of her

disorder. Despite her parents’ attempts to limit her workouts, she would secretly exercise

after meals, using this as a strategy to "burn off" the calories consumed. This behavior further

reinforced her restrictive eating patterns and prevented weight restoration.

 According to two U.S. epidemiological studies conducted in community samples, the

12-month prevalence of anorexia nervosa ranges from 0.0% to 0.05% with much higher rates

in women than in men (0% to 0.08% in women; 0% to 0.01% in men), and the lifetime

prevalence ranges from 0.60% to 0.80% (0.9% to 1.42% in women; 0.12% to 0.3% in men).

By contrast, one study of adolescents found similar rates in both genders (American

psychiatric association, 2018).

According to the Global Burden of Disease (GBD) 2016 study, the estimated prevalence

rate of anorexia nervosa in India was 22.3 per 100,000 people, with a significant burden

borne by females aged 15–19 years. The male-to-female ratio was approximately 1:4. This

study also noted an increase in prevalence rates from 1990 to 2016 (Institute for Health

Metrics and Evaluation, 2017).

Anorexia nervosa typically begins during adolescence or young adulthood, though rare

cases of onset before puberty or after age 40 have been documented. The disorder is often

triggered by stressful events, such as leaving home for college. Its course varies

widely—some individuals recover fully after one episode, while others experience relapse or

develop a chronic condition lasting years. Younger patients may show atypical symptoms,

such as denying a fear of fat, while older patients often present with signs of a prolonged

illness.

Remission within five years of onset is common, though rates are lower among

hospitalized individuals. Mortality rates are about 5% per decade, with deaths mainly due to

medical complications or suicide. Hospitalization may be necessary to restore weight and

manage complications (American Psychiatric Association, 2022).

Risk and Prognostic Factors

 Temperamental - Individuals who develop anxiety disorders or display obsessional traits

in childhood are at increased risk for developing anorexia nervosa.

Environmental - Historical and cross-cultural variability in the prevalence of anorexia

nervosa supports its association with cultures and settings in which thinness is valued.

Occupations and vocations that encourage thinness, such as modeling and elite athletics, are

also associated with increased risk.

Genetic and physiological - There is an increased risk for anorexia nervosa and for other

eating and psychiatric disorders among biological relatives of individuals with anorexia

nervosa. Genome-wide association studies have begun to identify specific risk loci, including

loci associated with other psychiatric disorders and with metabolic traits such as insulin

resistance and lipid profile. A range of brain abnormalities, many suggesting abnormal

processing of reward, has been described in anorexia nervosa using functional imaging

technologies such as functional magnetic resonance imaging and positron emission

tomography. The degree to which these findings reflect changes associated with malnutrition

versus primary abnormalities associated with the disorder is unclear.

Differential diagnosis of anorexia nervosa are medical conditions [e.g., gastrointestinal

disease, hyperthyroidism, occult malignancies, acquired immunodeficiency syndrome

(AIDS)], major depressive disorder, schizophrenia, substance use disorders, social anxiety

disorder, obsessive-compulsive disorder, and body dysmorphic disorder, bulimia nervosa and

avoidant/restrictive food intake disorder.

Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa.

Many individuals with anorexia nervosa report the presence of either an anxiety disorder or

symptoms of anxiety prior to onset of their eating disorder. OCD is described in some

individuals with anorexia nervosa, especially those with the restricting type. Alcohol use
disorder and other substance use disorders may also be comorbid with anorexia nervosa,

especially among those with the binge-eating/purging type.

Therapeutic techniques used to treat anorexia nervosa are cognitive behavioral therapy

(CBT), family-based therapy (FBT), nutritional counseling, dialectical behavior therapy

(DBT), medication and interpersonal psychotherapy (IPT).

According to the diathesis-stress model, biological diathesis (genetics or neurochemical

features) that lead to dysregulation in mood and eating behavior interacting with

psychological vulnerabilities including: low self esteem, need to seek perfectionism,

impulsivity, body dissatisfaction, and distorted body image and environmental factors such as

media based pressures, child maltreatment, family conflict, social pressures, abuse etc.

resulting in eating disorders.

Biological Factors. The biological causes of eating disorders can be identified on the

basis of the following:

Twin and Family Studies: Twin and family studies evince for the heritability of eating

disorders. The tendency to develop eating disorders runs in families i.e. biological relatives of

people with anorexia and bulimia have increased rates of these eating disorders themselves.

Studies suggest that relatives of people with eating disorders is 4 to 5 times higher, with rates

higher for female relatives of patients with anorexia. Researchers suggest that there is a

shared genetic composition for people with the different types of eating disorders, referred to

as the broader eating disorder phenotype. However, eating disorders are not as heritable as

are mood disorders and schizophrenia. A person might inherit a tendency to be emotional

responsive to stressful situation and as a consequence eat impulsively in an attempt to relieve

stress. This biological diathesis may interact with socio and psychological factors to lead to

development of eating disorders.

 In important twin studies of bulimia by Kendler and colleagues (1991) and of anorexia by

Walters and Kendler (1995), researchers used structured interviews to ascertain the

prevalence of the disorders among 2,163 female twins. In 23% of identical twin pairs, both

twins had bulimia, as compared with 9% of fraternal twins. Because no adoption studies have

yet been reported, strong sociocultural influences cannot be ruled out, and other studies have

produced inconsistent results (Fairburn, Cowen, & Harrison, 1999). For anorexia, numbers

were too small for precise estimates, but the disorder in one twin did seem to confer a

significant risk for both anorexia and bulimia in the co-twin. Bulik et al. (2006), in a large

twin study, estimated heritability at 0.56. Thus, the consensus is that genetic makeup is about

half of the equation among causes of anorexia and bulimia (Trace et al., 2013).

Biological Set-point: Our bodies have a biologically determined set point for weight that

is difficult to change. Whenever we move away from this biological set point, sensation of

hunger is created. The more we move away from set point, the more and more hungry we

become encouraging us to eat and gain weight in order to return to the set point. Chronic

dieting enhances the chances of an individual with bulimia feeling irresistible urge to binge

high calorie food.

Neurotransmitters. Serotonin is a neurotransmitter that is involved in obsessiveness,

mood disorders, and impulsivity. People with eating disorders respond well to

anti-depressants that target serotonin, thereby implying the role of serotonin in eating

disorders. However, it is difficult to identify whether disturbances in neurotransmitters are

causes or consequences of the disorder.

Socio-cultural Factors

The following are the main socio-cultural causes of eating disorder:

 Media: All cultures recognize ideal images by which men and women are judged as

worthy members of their sex. These images form an essential component of our body image,

that is, how we think, feel, and behave with regard to our bodies. Media technologies

(magazines, newspapers, television, movies, and now social networking websites) provide

information about what an ideal body looks. Although, irrespective of one's gender, people

are exposed to ideal body media images. Studies report that women are more vulnerable to

body image disturbances than men. Grabe, Ward, and Hyde (2008), reviewing 77 studies,

demonstrated a strong relationship between exposure to media images depicting the thin-ideal

body and body image concerns in women. An analysis of prime-time situation comedies

revealed that 12% of female characters were dieting and many were mak ing disparaging

comments about their body image (Tiggemann, 2002).

The body size of women in media is becoming unrealistically thin. Many young women

are being regularly bombarded with these unrealistically thin models and actors. If we look at

the body shape and size of Bollywood actresses from 1970s and compare them to current day

actresses, we would realize that the construct of ideal body for women has changed from

being voluptuous to [Link], use of technologies like airbrushing, digital alteration and

cosmetic surgery further increase the unrealistic nature of media images of women as

standards for self-evaluation. In many non-Western cultures for example in India, fatness

would be valued over thinness as a sign of prosperity. Thin people were considered to be

sickly and/or incompetent. However, over time after exposure to Western media, many Indian

women began to express concerns with their weights and body dissatisfaction.

Family Influences. About 1 out of 3 patients with anorexia report family dysfunction and

it was a factor that contributed to their eating disorder (Tozzi et Eating Disorders al., 2003).

The following features were observed in families of people with anorexia: parental
 overprotectiveness, rigidity, marital discord, control issues etc. Parents also exceptionally

value thinness, dieting and physical appearance, it is common to find family members

making disparaging statements about body weight and shape. Although it is difficult to

establish causality between family dysfunction and eating disorders as the direction could be

other way round also. For instance, having a member with eating disorder may affect the

family negatively in turn leading to increasing family dysfunction.

Psychological Factors. The main psychological causes of eating disorders are as follows:

Excessive focus on appearance and internalizing of thin ideal. Two individual risk

factors are the extent to which an individual places importance on appearance and

internalization of thin ideal contribute to the development of eating disorders. Excessive

focus on appearance is most predictive of a preoccupation with weight for young woman who

are generally more prone to anxiety. Internalization of thin ideal means the extent to which

one associates thin with desirable, attractive, popular and being happy. Internalization of thin

ideal is related to a wide range of problems that are thought to be risk factors for eating

disorder i.e. body dissatisfaction, dieting, and negative affect.

Body Dissatisfaction. When one’s own body image does not match with the ideal image

promulgated by the media then some young girls and women are likely to develop negative

feelings and perceptual biases regarding how fat they are. Such biases lead women to believe

that men prefer more slender shapes than they in fact do. Also, women feel more stringently

evaluated by their female peers than they themselves do. Increased body dissatisfaction is not

only a diagnostic criterion for eating disorders; it is likely to cause them.

Dieting. Some researchers believe that dieting is a risk factor for eating disorders. This is

because many women who developed eating disorders had a history of dieting. However, not

all those who diet eventually develop an eating disorder. Some of the factors that mediate the
relationship between dieting and eating disorders are body dissatisfaction, supervised diets

vs. self-started diets, and the negative emotional effect of failed diets. Supervised diets in

people are less likely to be linked to eating disorders than non-supervised diets by people

high on body dissatisfaction. In fact, researchers conclude that controlled and supervised

dieting is related to reduced symptoms of bulimia.

Negative Affect. Experience of negative affect is a causal factor for eating disorders.

Feeling bad makes us self-critical and we begin to magnify our flaws and shortcomings. It is

common to find wide spread negative self-evaluations like, “I’m fat, I’m useless, I’m a

failure” in people with eating disorders. Negative affect is what maintains binge episodes in

as people usually binge when they are stressed, low, or feel bad about themselves. Eating

high caloric food is comforting and helps them deal with negative affect temporarily.

Perfectionism. People with eating disorders are high on the trait of perfectionism or the

need to be exactly right. Perfectionist people are much more likely to prescribe to the thin

ideal and pursue a ‘perfect body.’ Perfectionism leads to rigid adherence to dieting that then

drives the binge/purge cycle in bulimia. Pope and colleagues (2000) confirmed that men

generally desire to be heavier and more muscular than they are. The authors measured the

height, weight, and body fat of college-age men in three countries—Austria, France, and the

United States. They asked the men to choose the body image that they felt represented (1)

their own body, (2) the body they ideally would like to have, (3) the body of an average man

of their age, and (4) the male body they believed was preferred by women. In all three

countries, men chose an ideal body weight approximately 28 pounds more muscular than

their current one. They also estimated that women would prefer a male body about 30 pounds

more muscular than their current one. In contradiction to the impression, Pope and colleagues

(2000) demonstrated, in a pilot study, that most women preferred an ordinary male body
without the added muscle. Men who abuse anabolic–androgenic steroids to increase muscle

mass and “bulk up” possess these distorted attitudes toward muscles, weight, and the “ideal

man” to a greater degree than men who don’t use steroids (Kanayama, Barry, & Pope, 2006).

In conclusion, anorexia nervosa is a complex and potentially life-threatening eating

disorder with psychological, biological, and sociocultural underpinnings. Its onset is often

associated with adolescence or young adulthood, marked by restrictive eating patterns,

intense fear of weight gain, and distorted body perception. The disorder’s trajectory varies

from full recovery to chronic relapse, with mortality rates significantly higher than other

psychiatric disorders due to medical complications and suicide. Early detection, accurate

diagnosis, and a combination of evidence-based therapies are critical to improving outcomes.

A multidisciplinary approach addressing the medical, nutritional, and psychological needs of

individuals offers the best chance for recovery and long-term remission.