Bundesverband der Angehörigen psychisch erkrankter Menschen e.V.

Eating disorders: Anorexia nervosa

Eating disorders are abnormalities in eating behaviour, which occur mainly in adolescent girls and young women in puberty. They are among the most common chronic health problems in childhood and adolescence. Young men, pre-pubescent children, and older women are more rarely affected.

Eating disorders are psychosomatic disorders. This means that they affect both the body and the mind. They are conditions of an addictive nature which can often take a severe course. They can present in “classic” form as anorexia, bulimia or binge eating disorder. But there are also mixed forms and it is often difficult in practice to make a clear distinction since some symptoms are similar. In the course of the condition one form can also merge into another. There are disorders which do not fulfil all the characteristics of anorexia or bulimia. This group of “non-typical” eating disorders occurs frequently in practice.  One thing that all eating disorders have in common is: the sufferer’s thoughts revolve constantly around eating or not eating and their figure. Their whole daily routine is organised around this. Simply eating is no longer possible. Eventually the eating disorder governs their whole lives. It destroys feelings, satisfaction, desire, enjoyment and relationships. It damages health and can be life-threatening. That’s why eating disorders must be treated.

People with anorexia are often very performance oriented and perfectionist in all areas of their lives. The control they gain over their bodies increases their self-esteem and gives them a feeling of power. Even when they are already thin to the point of skin and bone, they still perceive themselves too fat and are terrified of gaining weight. Sufferers are no longer able to see their bodies realistically.

The struggle with food (excessive consumption of food or refusal to eat) can be seen as a substitute for deeper psychological conflicts. The altered eating behaviour represents an attempt to find a solution. It serves as an escape or flight from suppressed needs and unpleasant feelings like stress, fear, despair and loneliness. Eating or starving themselves serves to temporarily dispel their inner tension. A feeling of safety and satisfaction is experienced. In order to maintain this feeling, the behaviour must be repeated. This causes the eating disorder to gain momentum with negative physical and psychological consequences.

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Characteristics of anorexia

Please note that the characteristics below can only be indications of anorexia and do not necessarily all occur at the same time; diagnosis can only be made by specialists

Body weight:

  • In adults weight is assessed according to the body mass index (BMI) [calculation: weight (kg) divided by height (m) x height (m)]. A BMI of less than 17.5 is considered a sign of anorexia. In children classification is by comparison to percentiles of children of the same age and gender [for more detail see e.g.].
  • Sometimes significant weight loss in a short time, or no weight gain despite growth
  • Considering themselves too fat although this is not the case
  • An emaciated body is disguised under wide clothing or conversely flaunted

Control of body weight:

  • Fasting
  • Excessive checking of weight
  • Extreme physical activity: the self-imposed exercise regime is then an absolute must that cannot be missed.
  • Forced vomiting, use of laxatives, diuretic tablets or enemas

Eating behaviour:

  • Eating very little; calorie counting
  • Limited choice of foodstuffs, "bans"
  • Cooking for others but not eating themselves
  • Avoiding eating with others ("not hungry", "already eaten")
  • Eating extremely slowly, eating rituals (what can be eaten when)
  • Stockpiling of food

Social behaviour:

  • Low self-esteem
  • Extreme performance orientation, perfectionism
  • Significant increase or drop in performance
  • Withdrawal from family, friends
  • Neglect of hobbies
  • Denial of problems

Physical symptoms:

  • Always cold
  • Weakness, dizziness, fainting
  • Frequent stomach pain
  • Swelling of the salivary glands ("hamster cheeks")
  • Stopping of periods

Risk factors

Experts believe that the development of anorexia stems from the interaction of certain biological, socio-cultural and psychological factors, the significance of which is however seen differently in the various models.

The risk factors include:

Biological/genetic factors:

  • Genetic disposition
  • Complications in pregnancy and childbirth

Social factors:

  • Beauty ideals
  • Changing expectations of role

Behaviour learned in social environment:

  • Attitudes to food, diets, evaluation of weight and figure
  • Attitudes to conflict, achievement, expectations

Temperament and personality:

  • Low self-esteem, fear of failure, strong need for harmony
  • High pressure to achieve (parents upon themselves and their children /adolescents upon themselves)
  • Protest against supervision, overprotection, excessive harmony
  • Battle for independence (feeling of powerlessness in life is countered by control over their own bodies)
  • Rejection of sexual development (wanting to remain a child)

Consequences of anorexia

The severity of the consequences of anorexia depends on the extent to which the condition takes hold. It is generally true that the consequences are much more severe the younger the child, the less s/he weighs and the faster s/he loses weight.

Over 5% of those affected die from the disease, some sources put the death rate even higher.

Physical consequences

The poor nutrition affects the whole metabolism and all the organs. Particularly common effects are: electrolyte deficiencies, cardiac and vascular effects, hormone imbalance, stomach and intestinal complaints, growth deficiency, later on osteoporosis.

Psychological consequences

Starving yourself causes psychological illness (even healthy people who are forced to starve). Obsessive-compulsive disorders, anxiety disorders and depression often accompany anorexia. On the other hand there are indications that these conditions can encourage anorexia.

Missed puberty

In puberty there is a move towards adult life. People with anorexia miss this phase and thus important development steps.


Just as the consequences of anorexia depend on the severity of the condition, so too does the appropriate treatment. In mild cases outpatient treatment may be sufficient, in more severe cases hospital admission or part-time residential care may be necessary. A therapeutic living community can also help. In the case of children and adolescents, parents are usually involved in the treatment.

It can be months or years before full recovery is made from an eating disorder. So it is important that all those involved don’t lose hope or courage.

Each therapy consists of several supplementary components (integrative or multimodal approach). These components include:

Advice centre for eating disorders (drop-in, telephone, Internet)

Evaluation of the situation, provision of information, motivation to treatment


The main focus of treatment for eating disorders. This uses mainly two procedures, the costs of which are reimbursed by health insurers: cognitive behavioural therapy and depth psychological psychotherapy. In addition there is also psychoanalysis, interpersonal psychotherapy and systemic family therapy. You should find out in advance the extent to which your health insurer will assume these costs. Depending on the specific situation either individual or group therapy is used.

Medical treatment

Monitoring of weight changes, treatment of accompanying physical conditions

Supportive nutritional therapy

Nutritional advice specifically tailored to eating disorders

Supplementary therapies

Relaxation, body awareness, dance, design, music or art therapy

Self help

Self-help programmes for those affected can support treatment, but never replace it. Self-help for relatives offers the opportunity to talk to other parents or relatives.

After care

Confirmation of treatment success; avoidance of relapses

Tips for parents and other relatives

  • If you suspect your child might be anorexic don’t close your eyes to it. This disease makes many parents feel helpless. Remind yourself that eating disorders are psychosomatic conditions with addictive nature and find out all you can about the disorder (leaflets, advice centres).
  • An eating disorder doesn’t just affect the child suffering from the condition but rather the whole family structure. Apportioning blame upon the other partner and the child is not helpful. Try instead to find ways out of the situation and support the child. If at all possible do not make decisions over his or her head.
  • Speak about the problem openly; don’t dramatise it, but don’t play it down either; try to stay calm. Talk about your fears without apportioning blame and concentrate on changes in the child’s behaviour. The child will probably deny the problems, perhaps also react aggressively or seek to explain away their changed behaviour. This is typical for eating disorders. Don’t let yourself be fobbed off or shut out.
  • Insist on a visit to the doctor and encourage approaching an advice centre. But be aware that you will need lots of patience, even constant reasoning will often not help for a long time. The person affected must decide for themselves when to ask for help.
  • In severe cases anorexia can be life-threatening. If you fear such a situation, go to a doctor immediately or have your child admitted to a clinic, if necessary against their will – this can save your child’s life.
  • The same applies if you have (hidden) indications that the child is harbouring thoughts of suicide or even has attempted suicide in the past. Don’t hesitate to get help. Remember that admission to a clinic (child psychiatric or psychosomatic clinic) can only be ordered by a doctor.
  • In crisis situations you can also contact the “Sozialpsychiatrischer Dienst” (social psychiatric service) which is available in every town or district. It may be helpful to keep the phone number handy for emergencies.
  • Accept that you cannot treat your child’s illness. Leave therapy to the experts (doctor, psychotherapist). Keep yourself informed as to the nature and goals of treatment. If you support the treatment that can be a valuable help.
  • Agree rules for joint mealtimes; such conversations are often best handled in the presence of a neutral third party.
  • Despite your worry, try not to allow your child’s eating disorder to dominate family life. Allow yourself time off to recharge your batteries and don’t forget that your partner and other children have their own needs. Give them your attention and time.

Further Information The largest German language self-help group for people with eating disorders and their relatives; information, forum, chat Federal Centre for Health Education; leaflets, advice line (also available on Saturday and Sunday), advice centre addresses Federal Association of Child and Adolescent Helplines; telephone and e-mail advice for children and adolescents from professional advisors or adolescents for other adolescents; telephone helpline for parents. a wide range of advisory services by the Federal Conference for Parent Counselling for parents and young people, addresses of advice centres, moderated forum, chats.

Beware of the websites Pro Ana and Pro Mia! Pages like these contain advice for persons affected on how to keep losing weight, hide their weight loss or avoid therapy.