Internet Mental Health


Diagnostic Features of Anorexia Nervosa

Terrified of Being Fat Is obsessed with weight loss and is phobic of weight gain "I absolutely dread being fat or flabby."
Hates Own Body Shape and Size Overvalues thinness; hates own body shape and size "I'm fat and I can never be too thin."
Compulsively Attempts To Lose Weight Attempts to lose weight by compulsive dieting, exercising, self-induced vomiting, laxative/diuretic abuse "To lose weight, I'm always dieting, exercising, vomiting, or using laxatives/water pills (diuretics)."
Denies Obvious Starvation Is pathologically thin but denies this "I like being thin like I am now, but I want to be thinner."
Self-Imposed Starvation Causes Harm Self-imposed starvation can be lethal "Some people say I'm much too thin, but I'm not."


    This disorder consists of overvaluing thinness, developing a phobia about being fat, obsessing about it, and compulsively dieting to the point of life-threatening starvation. It may last from a few months to many years.


    Occupational-Economic :

    • When severe, causes academic/vocational impairment.

    Perfectionistic, Overcontrolled (High Conscientiousness):

    • Many have obsessive-compulsive personality traits: strong need to control one's environment, inflexible thinking, limited social spontaneity, perfectionism, overly restrained initiative and emotional expression

    Emotional Distress (Negative Emotion) :

    • Pathologically thin, yet obsessed with weight loss, phobic of weight gain, and markedly dissatisfied with own body size and shape

    • Primarily caloric restriction, but also food binging and purging (by self-induced vomiting, laxative abuse, or diuretic abuse)

    • May cycle between having Anorexia Nervosa (caloric restriction), and having Bulimia Nervosa (food binging)

    • Some develop Obsessive-Compulsive Disorder (not related to food).

    • When severe, many develop Major Depressive Disorder, anger, decreased interest in sex, suicide attempts

    Medical :

    • Illness denial is common.

    • Starvation can be life-threatening: 12% mortality rate; hospitalization may be required to prevent death from starvation, suicide, or electrolyte imbalance; medical symptoms are those caused by starvation (e.g., emaciation; cessation of menstruation; abnorally low blood pressure, body temperature, and heart rate; peripheral edema); serious medical conditions can result (e.g., anemia, impaired renal function, cardiovascular problems, dental enamel erosion from self-induced vomiting, and osteoporosis)

SAPAS Personality Screening Test

Individuals with this disorder would have a significant impairment in the behaviors that are displayed in red :

Most of the time and in most situations:

      In general, do you have difficulty making and keeping friends?
      Would you normally describe yourself as a loner?
      In general, do you trust other people? ("No")
      Do you normally lose your temper easily?
      Are you normally an impulsive sort of person?
      Are you normally a worrier?
      In general, do you depend on others a lot?
      In general, are you a perfectionist?

7-Question Well-Being Screening Test (By P. W. Long MD, 2020

Individuals with this disorder would have a significant impairment in the behaviors that are displayed in red :

      Agreeableness: I was kind and honest.
      Conscientiousness: I was diligent and self-disciplined.
      Openness/Intellect: I showed good problem-solving and curiosity.
      Sociality: I was gregarious, enthusiastic, and assertive.
      Emotional Stability: I was emotionally stable and calm. (Instead was obsessed with weight loss, terrifed of weight gain, compulsively attempted to lose weight, overvalued thinness, hated own body shape and size, denied own obvious starvation)
      Physical Health: I was physically healthy. (Instead had potentially lethal self-imposed starvation)
      Role Functioning: I functioned well socially and at school/work.

How often in the past week did you do each of these 7 behaviors:

Fear, Phobia, Obsession, Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Phobia:
    If fear about about a specific object or situation becomes excessive, it is defined as a phobia. This phobic fear is out of proportion to the actual danger posed by the specific object or situation, and this phobic fear causes significant distress or disability. In anorexia nervosa, the individual develops a phobia about gaining weight and being fat.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is an unwanted, recurrent, persistent, fear-provoking intrusive thought. In anorexia nervosa, individuals have unwanted, intrusive thoughts about their fear of being overweight. Thus their life becomes centered around how to lose more weight.

  • Compulsion:
    A compulsion is a ritual an individual develops to combat an obsession. Thus compulsions are fear-relieving avoidance behaviors. The individual feels driven to perform these compulsions. In anorexia nervosa, the individual develops compulsive weight-reducing behaviors (e.g., compulsive: dieting, exercising, self-induced vomiting, or abuse of laxatives or diuretics). Some of these compulsive rituals may spawn other, illogically related compulsions (e.g., "I must avoid eating red foods"). This irrationality is the hallmark of superstitious learning.

Back to top

Diagnose Anorexia Nervosa

Diagnose Eating Disorders

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Anorexia Nervosa 307.1

This diagnosis is based on the following findings:
  • Restriction of food intake leading to a significantly low body weight (still present)
  • Felt 'too fat' even when obviously underweight (still present)
  • Intense fear of gaining weight or becoming fat, even though underweight (still present)

Treatment Goals:

  • Goal: prevent severe restriction of food intake.
    If this problem worsened: This could result in potentially life-threatening medical complications associated with malnutrition. Individuals with anorexia nervosa often do not recognize the serious medical implications of their malnourished state. They frequently either lack insight into or deny the problem.

  • Goal: correct disturbance in self-perceived weight or shape.
    If this problem worsened: Her self-esteem will become highly dependent on her perception of her body shape and weight. Weight loss will become valued as an impressive achievement and a sign of extraordinary self-discipline, whereas weight gain will be perceived as an unacceptable failure of self-control.

  • Goal: prevent intense fear of gaining weight or becoming fat.
    If this problem worsened: Her intense fear of becoming fat usually will not be alleviated by weight loss. In fact, concern about weight gain may increase even as weight falls. Younger individuals with anorexia nervosa, as well as some adults, may not recognize or acknowledge a fear of weight loss. However, the clinician may infer that this fear exists in the absence of another explanation for the significantly low weight.

Back to top

Diagnostic Features

Anorexia Nervosa is characterized by deliberate weight loss most commonly in adolescent girls and young women. This disorder is characterized by a phobic fear of getting fat, an obsession with thinness, and compulsive self-starvation. A point is reached in dieting when genetic and physiological factors kick in, and food restriction behaviors become compulsive and very difficult to stop. These compulsive behaviors include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics. There is undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function.

Researchers are finding that anorexia nervosa and obsessive-compulsive personality disorder share many common features: perfectionism, inflexibility, having to follow the rules, excessive doubt and caution, and a drive for order and symmetry. As many as three-quarters of those with anorexia nervosa have suffered from an anxiety disorder before their eating disorder began, most commonly social anxiety and OCD.

When exposed to food, a typical individual with anorexia nervosa reported that she suffers from a constant stream of self-loathing: "I can't eat this. I'm going to get fat. I'm ugly. I'm disgusting. I'm weak. I hate myself. I can't do this. I'm so pathetic, just pathetic, a weak pig."

Individuals with anorexia nervosa and bulimia nervosa share many similar features. In both disorders, individuals have an obsession with weight loss, a phobia of weight gain, and marked dissatisfaction with their body size and shape. Both disorders can have self-imposed caloric restriction, food binging and purging (by self-induced vomiting, laxative abuse, or diuretic abuse). Some individuals cycle back and forth between anorexia and bulimia. Anorexic individuals restrict their caloric intake far more than bulimic individuals do; thus anorexics are pathologically thin, whereas many bulimics have a normal weight. Bulimic individuals binge more than anorexic individuals. The risk of onset of anorexia nervosa is highest in late adolescence, with 40% of new cases found between ages 15 and 19 years, and drops significantly after 21 years of age.

There is an argument that Anorexia Nervosa is a form of Obsessive-Compulsive Disorder combined with Body Dysmorphic Disorder in which individuals are obsessed with thinness and their body image, and compulsively diet to change their distorted body image.

Individuals with Anorexia Nervosa view their weight loss as an admirable sign of extraordinary self-discipline, whereas they any view weight gain as a sign of failure of self-control. They seldom appreciate how medically dangerous self-imposed starvation can be. Worse still, there are now pro-anorexia and pro-bulimia support websites that promote and glorify anorexia and bulimia. These websites are medically very dangerous and should be strictly avoided.

Historically, eating disorders were a medical rarity prior to World War I. Then, after fashion magazines were introduced, the incidence of anorexia nervosa shot up. Thus the current epidemic of eating disorders started after World War I in America, spread to Europe, and only after World War II spread to Asia. In Canada's far north, eating disorders were historically unknown in previous generations of aboriginals. The current older aboriginal generation was largely protected from Western influences by a language barrier, but younger aboriginals now speak English. Historically, for the first time, eating disorders are starting to appear in young aboriginals. Thus exposure to Western culture appears to be causal in the development of eating disorders.


Anorexia Nervosa has a 12% mortality rate from medical complications or suicide. Some develop significant impairment of their functioning at school, job or housekeeping. Others may develop significant social isolation.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder. However, there are many physiological disturbances (including amenorrhea and vital sign abnormalities) caused by this self-imposed starvation. Most of the physiological disturbances are reversible with nutritional rehabilitation. However, loss of bone mineral density is not completely reversible. Some individuals with this disorder exhibit no laboratory abnormalities.


The 12 month prevalence of Anorexia Nervosa is 0.4% among young women. This disorder has a 10:1 female-to-male ratio.


Anorexia Nervosa usually starts during adolescence or young adulthood. It rarely begins before puberty or after age 40. The onset is often associated with a stressful event which triggers an individual to start dieting. The course and outcome of this disorder is quite variable. Some individuals recover fully after a single episode; some have recurrent episodes of Anorexia and Bulimia; others experience a chronic course over many years.


A recent study found reported: "About two-thirds of individuals with anorexia nervosa or bulimia nervosa have one or more lifetime anxiety disorder; the most common is obsessive-compulsive disorder (OCD) [41%] and social phobia [20%]. The majority report the onset of OCD, social phobia, specific phobia, and generalized anxiety disorder in childhood, before they developed their eating disorder. People with a history of an eating disorder who were not currently ill and never had a lifetime anxiety disorder diagnosis still tended to be anxious, perfectionistic, and harm avoidant." Another study reported that the lifetime prevalence of OCD ranged from 9.5 to 62% in patients with anorexia nervosa or bulimia nervosa. Anorexia Nervosa also frequently co-occurs with Mood Disorders (bipolar and depressive), Avoidant Personality Disorder and Substance Use Disorders (alcohol and drugs). Some individuals cycle between episodes of Anorexia Nervosa and Bulimia Nervosa.


At least 12% die from medical complications or suicide. Among the surviving patients, less than one-half recover on average, whereas one-third improve, and 20% remain chronically ill. Long-term support is necessary in order to prevent recurrence.

Risk Factors and Precipitants

Children with Anxiety Disorders or obsessional traits have an increased risk of developing Anorexia Nervosa. Culture plays a major role in Anorexia Nervosa since this disorder is only present in cultures that over-value thinness. Occupations that over-value thinness (e.g., modeling, ballet dancing) have a very high rate of this disorder.

Familial Pattern

There is an increased risk for both Anorexia Nervosa and Bulimia Nervosa among first-degree biological relatives of individuals with Anorexia Nervosa. It appears that vulnerability to Anorexia Nervosa is genetic. Concordance rates for anorexia nervosa in monozygotic twins are significantly higher than those for dizygotic twins.

Effective Therapies

Family-based treatment has the best evidence base for effectiveness for younger patients. For adults no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy is recommended. Medication plays a limited role in Anorexia Nervosa (but a major role in Bulimia Nervosa). For Anorexia Nervosa, the most important medicine is food. Hospitalization frequently saves the lives of individuals with Anorexia Nervosa who have life-threatening medical complications. The effectiveness of outpatient psychotherapy for Anorexia Nervosa is inconclusive. However, patients who do not receive psychotherapy (e.g. are in a waiting-list control group or who get 'treatment as usual') do poorly. Cognitive Behavioural Therapy (CBT) for Anorexia Nervosa is not consistently superior to other treatments (including dietary counselling, non-specific supportive management, interpersonal therapy, behavioural family therapy).

Ineffective therapies

Research has shown that nutritional counselling alone has little benefit. In one study, all those in the control group who got only 'dietary advice' dropped out. Vitamins and dietary supplements are only effective during the acute recovery stage following severe starvation. Vitamin or dietary supplement therapy alone is ineffective.

Trustworthy Research (

A Dangerous Cult

Back to top


  • Anorexia Nervosa - Google
  • Anorexia Nervosa In Childhood - Child Mind Institute
  • Anorexia Nervosa - Epocrates Online
  • Anorexia Nervosa World Health Organization ICD-10 (2010)
  • Eating Disorders - NIMH
  • Anorexia Nervosa - PubMed Health
  • Anorexia Nervosa - Wikipedia
  • Anorexia Nervosa Genetics Online Mendelian Inheritance in Man
  • Childhood Obsessive-Compulsive Personality Traits in Adult Women With Eating Disorders - This 2003 study found that childhood traits reflecting obsessive-compulsive personality disorder appear to be important risk factors for the development of eating disorders. This study identified five personality traits that increased the risk of developing an eating disorder: perfectionism, inflexibility, having to follow the rules, excessive doubt and caution, and a drive for order and symmetry. These are exactly the same symptoms which define obsessive-compulsive personality disorder.
  • Why it's so difficult to treat adult anorexia - Researchers are finding that anorexia nervosa and obsessive-compulsive personality disorder share many common features. As many as three-quarters of those with anorexia nervosa have suffered from an anxiety disorder before their eating disorder began, most commonly social anxiety and Obsessive-Compulsive Disorder. This article discusses how a family-assisted 5-day intensive treatment program for adults with anorexia nervosa is helping these individuals by using these new insights.


Rating Scales

You Can Watch A Video Of What Happens To People After 4 Days Of Starvation

Recently there was a 10 day experiment in which 10 individuals agreed to be cavemen and go into the Colorado wildness equipped only with caveman clothing and tools. This experiment quickly became a study of what happens to normal people when they starve.

Psychiatrically, the results were amazing.

The group was able to catch fish on the first day, then they ran out of food. By the fourth day of starvation, the entire group suffered from severe fatigue, insomnia and apathy. Three members of the group became dysfunctional and just spent the day lying down or sitting. One woman, a vegetarian, was very weak and inactive because she couldn't find nutritious vegetarian food. Another female member became very tearful, pessimistic, and emotionally unstable. This woman gave up on the fifth day of starvation, and exited the experiment.
On the sixth day of starvation, a male member of the group just gave up, and said that they had no chance of getting any more food. He then exited the experiment.

Fortunately, on the seventh day of starvation, the four group members that still had the energy and optimism to hunt, actually killed an elk using their caveman spears. To everyone's surprise, the vegetarian woman refused to eat the meat, and - had the experiment run longer than 10 days - would have starved to death.

When you watch the video of this caveman experiment, you can see practically all of the symptoms of major depressive disorder appear. By the fourth day of starvation, all the group had developed severe fatigue, insomnia, hunger, apathy, and half the group developed crippling pessimism. Those that exited the experiment had developed marked loneliness and social withdrawal. In addition, the woman that exited the group had developed emotional instability. The vegetarian's meat-refusal, even if it meant her starvation, could be interpreted as perfectionism and inflexibility. By the 7th day of starvation, 4 group members were still functional (and saved the group by going hunting), and the other 4 remaining members were dysfunctional and so fatigued and apathetic that all they could do is stay in the camp and lie down.

What Did This Experiment Teach Us About Anorexia Nervosa?

Research has repeatedly shown that starvation can trigger Major Depressive Disorder. Thus, it should come as no surprise that self-imposed starvation (Anorexia Nervosa) can also trigger Major Depressive Disorder. What this Caveman Experiment demonstrates is how quickly starvation can trigger uncooperative, oppositional behavior. By the sixth day of this starvation experiment, 6 out of the 10 group members had become so dysfunctional that they couldn't hunt. Two of them became so emotionally upset that they quit the experiment in anger. The other four became so apathetic and oppositional that they refused to hunt. They had lost hope and had given up.

It appeared that the 6 group members that refused to hunt had lost their focus and creativity, and couldn't figure out how to solve their starvation problem. They couldn't see that they would have to be move closer to the elk. All they could do was to become immobilized. Some showed bad judgment by prematurely quitting the experiment. One showed extremely poor judgment by refusing the meat offered to her even though she was starving. Her inflexible vegetarian beliefs would have killed her had the experiment continued.

Thus, in this 10 day experiment in starvation, we can see many of the starvation behaviors that we see in Anorexia Nervosa:

  • Uncooperative, oppositional behavior

  • Socially withdrawn, unfriendly behavior

  • Loss of focus on goal-oriented activity

  • Loss of creativity and impaired problem-solving

  • Poor judgment and inflexible, closed-mindedness

  • Apathy and loss of motivation

  • Inability to work

  • Quickly giving up instead of persisting in the face of adversity

  • Pessimism, expecting the worst

This experiment shows how quickly normal people can develop very dysfunctional behavior during starvation. That is why self-imposed starvation from severe dieting is so dangerous. Self-imposed starvation can trigger powerful dysfunctional behaviors that further reinforce the dieting, potentially leading to tragedy.

Back to top

Diagnostic Features of Anorexia Nervosa

Terrified of Becoming Fat
Hates Own Body Shape and Size
Compulsively Attempts To Lose Weight
Denies Obvious Starvation
Self-Imposed Starvation Causes Harm

Anorexia Nervosa F50.0 - ICD10 Description, World Health Organization

A disorder characterized by deliberate weight loss, induced and sustained by the patient. It occurs most commonly in adolescent girls and young women, but adolescent boys and young men may also be affected, as may children approaching puberty and older women up to the menopause. The disorder is associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves. There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function. The symptoms include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics.

Anorexia Nervosa - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with anorexia nervosa needs to meet all of the following criteria:

  • 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.

  • Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

  • 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.

  • Specify whether:

  • Restricting type: During the past 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

  • Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Back to top

Treatment Guidelines

Summary Of Practice guideline for the treatment of patients with eating disorders. - American Psychiatric Association (2006)

Rating Scheme for the Strength of the Recommendations

Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence:

  • [I] Recommended with substantial clinical confidence.

  • [II] Recommended with moderate clinical confidence.

  • [III] May be recommended on the basis of individual circumstances.

Choice of Specific Treatments for Anorexia Nervosa

The aims of treating anorexia nervosa are to 1) restore patients to a healthy weight (associated with the return of menses and normal ovulation in female patients, normal sexual drive and hormone levels in male patients, and normal physical and sexual growth and development in children and adolescents); 2) treat physical complications; 3) enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation and self-esteem and behavioral problems; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse.

  1. Nutritional Rehabilitation

    The goals of nutritional rehabilitation for seriously underweight patients are to restore weight, normalize eating patterns, achieve normal perceptions of hunger and satiety, and correct biological and psychological sequelae of malnutrition [I]. For patients age 20 years and younger, an individually appropriate range for expected weight and goals for weight and height may be determined by considering measurements and clinical factors, including current weight, bone age estimated from wrist x-rays and nomograms, menstrual history (in adolescents with secondary amenorrhea), mid-parental heights, assessments of skeletal frame, and benchmarks from Centers for Disease Control and Prevention (CDC) growth charts [I].

    For individuals who are markedly underweight and for children and adolescents whose weight has deviated below their growth curves, hospital-based programs for nutritional rehabilitation should be considered [I]. For patients in inpatient or residential settings, the discrepancy between healthy target weight and weight at discharge may vary depending on patients' ability to feed themselves, their motivation and ability to participate in aftercare programs, and the adequacy of aftercare, including partial hospitalization [I]. It is important to implement refeeding programs in nurturing emotional contexts [I]. For example, it is useful for staff to convey to patients their intention to take care of them and not let them die even when the illness prevents the patients from taking care of themselves [II]. It is also useful for staff to communicate clearly that they are not seeking to engage in control battles and have no punitive intentions when using interventions that the patient may experience as aversive [I].

    In working to achieve target weights, the treatment plan should also establish expected rates of controlled weight gain. Clinical consensus suggests that realistic targets are 2-3 pounds (lb)/week for hospitalized patients and 0.5-1 lb/week for individuals in outpatient programs [II]. Registered dietitians can help patients choose their own meals and can provide a structured meal plan that ensures nutritional adequacy and that none of the major food groups are avoided [I]. Formula feeding may have to be added to the patient's diet to achieve large caloric intake [II]. It is important to encourage patients with anorexia nervosa to expand their food choices to minimize the severely restricted range of foods initially acceptable to them [II]. Caloric intake levels should usually start at 30-40 kilocalories/kilogram (kcal/kg) per day (approximately 1,000-1,600 kcal/day). During the weight gain phase, intake may have to be advanced progressively to as high as 70-100 kcal/kg per day for some patients; many male patients require a very large number of calories to gain weight [II].

    Patients who require much lower caloric intakes or are suspected of artificially increasing their weight by fluid loading should be weighed in the morning after they have voided and are wearing only a gown; their fluid intake should also be carefully monitored [I]. Urine specimens obtained at the time of a patient's weigh-in may need to be assessed for specific gravity to help ascertain the extent to which the measured weight reflects excessive water intake [I]. Regular monitoring of serum potassium levels is recommended in patients who are persistent vomiters [I]. Hypokalemia should be treated with oral or intravenous potassium supplementation and rehydration [I].

    Physical activity should be adapted to the food intake and energy expenditure of the patient, taking into account the patient's bone mineral density and cardiac function [I]. Once a safe weight is achieved, the focus of an exercise program should be on the patient's gaining physical fitness as opposed to expending calories [I].

    Weight gain results in improvements in most of the physiological and psychological complications of semistarvation [I]. It is important to warn patients about the following aspects of early recovery [I]: As they start to recover and feel their bodies getting larger, especially as they approach frightening, magical numbers on the scale that represent phobic weights, they may experience a resurgence of anxious and depressive symptoms, irritability, and sometimes suicidal thoughts. These mood symptoms, non-food-related obsessional thoughts, and compulsive behaviors, although often not eradicated, usually decrease with sustained weight gain and weight maintenance. Initial refeeding may be associated with mild transient fluid retention, but patients who abruptly stop taking laxatives or diuretics may experience marked rebound fluid retention for several weeks. As weight gain progresses, many patients also develop acne and breast tenderness and become unhappy and demoralized about resulting changes in body shape. Patients may experience abdominal pain and bloating with meals from the delayed gastric emptying that accompanies malnutrition. These symptoms may respond to pro-motility agents [III]. Constipation may be ameliorated with stool softeners; if unaddressed, it can progress to obstipation and, rarely, to acute bowel obstruction.

    When life-preserving nutrition must be provided to a patient who refuses to eat, nasogastric feeding is preferable to intravenous feeding [I]. When nasogastric feeding is necessary, continuous feeding (i.e., over 24 hours) may be better tolerated by patients and less likely to result in metabolic abnormalities than three to four bolus feedings a day [II]. In very difficult situations, where patients physically resist and constantly remove their nasogastric tubes, feeding through surgically placed gastrostomy or jejunostomy tubes may be an alternative to nasogastric feeding [II]. In determining whether to begin involuntary forced feeding, the clinician should carefully think through the clinical circumstances, family opinion, and relevant legal and ethical dimensions of the patient's treatment [I]. The general principles to be followed in making the decision are those directing good, humane care; respecting the wishes of competent patients; and intervening respectfully with patients whose judgment is severely impaired by their psychiatric disorders when such interventions are likely to have beneficial results [I]. For cooperative patients, supplemental overnight pediatric nasogastric tube feeding has been used in some programs to facilitate weight gain [III].

    With severely malnourished patients (particularly those whose weight is <70% of their healthy body weight) who undergo aggressive oral, nasogastric, or parenteral refeeding, a serious refeeding syndrome can occur. Initial assessments should include vital signs and food and fluid intake and output, if indicated, as well as monitoring for edema, rapid weight gain (associated primarily with fluid overload), congestive heart failure, and gastrointestinal symptoms [I]. Patients' serum levels of phosphorus, magnesium, potassium, and calcium should be determined daily for the first 5 days of refeeding and every other day for several weeks thereafter, and electrocardiograms should be performed as indicated [II]. For children and adolescents who are severely malnourished (weight <70% of healthy body weight), cardiac monitoring, especially at night, may be desirable [II]. Phosphorus, magnesium, and/or potassium supplementation should be given when indicated [I].

  1. Psychosocial Interventions

    The goals of psychosocial interventions are to help patients with anorexia nervosa 1) understand and cooperate with their nutritional and physical rehabilitation, 2) understand and change the behaviors and dysfunctional attitudes related to their eating disorder, 3) improve their interpersonal and social functioning, and 4) address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors.

    1. Acute Anorexia Nervosa

      During acute refeeding and while weight gain is occurring, it is beneficial to provide anorexia nervosa patients with individual psychotherapeutic management that is psychodynamically informed and provides empathic understanding, explanations, praise for positive efforts, coaching, support, encouragement, and other positive behavioral reinforcement [I]. Attempts to conduct formal psychotherapy with starving patients who are often negativistic, obsessional, or mildly cognitively impaired may be ineffective [II].

      For children and adolescents, the evidence indicates that family treatment is the most effective intervention [I]. In methods modeled after the Maudsley approach, families become actively involved, in a blame-free atmosphere, in helping patients eat more and resist compulsive exercising and purging. For some outpatients, a short-term course of family therapy using these methods may be as effective as a long-term course; however, a shorter course of therapy may not be adequate for patients with severe obsessive-compulsive features or nonintact families [II].

      Most inpatient-based nutritional rehabilitation programs create a milieu that incorporates emotional nurturance and a combination of reinforcers that link exercise, bed rest, and privileges to target weights, desired behaviors, feedback concerning changes in weight, and other observable parameters [II]. For adolescents treated in inpatient settings, participation in family group psychoeducation may be helpful to their efforts to regain weight and may be equally as effective as more intensive forms of family therapy [III].

    1. Anorexia Nervosa after Weight Restoration

      Once malnutrition has been corrected and weight gain has begun, psychotherapy can help patients with anorexia nervosa understand 1) their experience of their illness; 2) cognitive distortions and how these have led to their symptomatic behavior; 3) developmental, familial, and cultural antecedents of their illness; 4) how their illness may have been a maladaptive attempt to regulate their emotions and cope; 5) how to avoid or minimize the risk of relapse; and 6) how to better cope with salient developmental and other important life issues in the future. Clinical experience shows that patients may often display improved mood, enhanced cognitive functioning, and clearer thought processes after there is significant improvement in nutritional intake, even before there is substantial weight gain [II].

      To help prevent patients from relapsing, emerging data support the use of cognitive-behavioral psychotherapy for adults [II]. Many clinicians also use interpersonal and/or psychodynamically oriented individual or group psychotherapy for adults after their weight has been restored [II]. For adolescents who have been ill <3 years, after weight has been restored, family therapy is a necessary component of treatment [I]. Although studies of different psychotherapies focus on these interventions as distinctly separate treatments, in practice there is frequent overlap of interventions [II].

      It is important for clinicians to pay attention to cultural attitudes, patient issues involving the gender of the therapist, and specific concerns about possible abuse, neglect, or other developmental traumas [II]. Clinicians need to attend to their countertransference reactions to patients with a chronic eating disorder, which often include beleaguerment, demoralization, and excessive need to change the patient [I]. At the same time, when treating patients with chronic illnesses, clinicians need to understand the longitudinal course of the disorder and that patients can recover even after many years of illness [I]. Because of anorexia nervosa's enduring nature, psychotherapeutic treatment is frequently required for at least 1 year and may take many years [I].

      Anorexics and Bulimics Anonymous and Overeaters Anonymous are not substitutes for professional treatment [I]. Programs that focus exclusively on abstaining from binge eating, purging, restrictive eating, or excessive exercising (e.g., 12-step programs) without attending to nutritional considerations or cognitive and behavioral deficits have not been studied and therefore cannot be recommended as the sole treatment for anorexia nervosa [I]. It is important for programs using 12-step models to be equipped to care for patients with the substantial psychiatric and general medical problems often associated with eating disorders [I].

      Although families and patients are increasingly accessing worthwhile, helpful information through online web sites, newsgroups, and chat rooms, the lack of professional supervision within these resources may sometimes lead to users' receiving misinformation or create unhealthy dynamics among users. It is recommended that clinicians inquire about a patient's or family's use of Internet-based support and other alternative and complementary approaches and be prepared to openly and sympathetically discuss the information and ideas gathered from these sources [I].

    1. Chronic Anorexia Nervosa

      Patients with chronic anorexia nervosa generally show a lack of substantial clinical response to formal psychotherapy. Nevertheless, many clinicians report seeing patients with chronic anorexia nervosa who, after many years of struggling with their disorder, experience substantial remission, so clinicians are justified in maintaining and extending some degree of hope to patients and families [II]. More extensive psychotherapeutic measures may be undertaken to engage and help motivate patients whose illness is resistant to treatment [II] or, failing that, as compassionate care [I]. For patients who have difficulty talking about their problems, clinicians have reported that a variety of nonverbal therapeutic methods, such as the creative arts, movement therapy programs, and occupational therapy, can be useful [III]. Psychosocial programs designed for patients with chronic eating disorders are being implemented at several treatment sites and may prove useful [II].

  1. Medications and Other Somatic Treatments
    1. Weight Restoration

      The decision about whether to use psychotropic medications and, if so, which medications to choose will be based on the patient's clinical presentation [I]. The limited empirical data on malnourished patients indicate that selective serotonin reuptake inhibitors (SSRIs) do not appear to confer advantage regarding weight gain in patients who are concurrently receiving inpatient treatment in an organized eating disorder program [I]. However, SSRIs in combination with psychotherapy are widely used in treating patients with anorexia nervosa. For example, these medications may be considered for those with persistent depressive, anxiety, or obsessive-compulsive symptoms and for bulimic symptoms in weight-restored patients [II]. A U.S. Food and Drug Administration (FDA) black box warning concerning the use of bupropion in patients with eating disorders has been issued because of the increased seizure risk in these patients. Adverse reactions to tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are more pronounced in malnourished individuals, and these medications should generally be avoided in this patient population [I]. Second-generation antipsychotics, particularly olanzapine, risperidone, and quetiapine, have been used in small series and individual cases for patients, but controlled studies of these medications are lacking. Clinical impressions suggest that they may be useful in patients with severe, unremitting resistance to gaining weight; severe obsessional thinking; and denial that assumes delusional proportions [III]. Small doses of older antipsychotics such as chlorpromazine may be helpful prior to meals in very disturbed patients [III]. Although the risks of extrapyramidal side effects are less with second-generation antipsychotics than with first-generation antipsychotics, debilitated anorexia nervosa patients may be at a higher risk for these than expected. Therefore, if these medications are used, it is recommended that patients be carefully monitored for extrapyramidal symptoms and akathisia [I]. It is also important to routinely monitor patients for potential side effects of these medications, which can result in insulin resistance, abnormal lipid metabolism, and prolongation of the QTc interval [I]. Because ziprasidone has not been studied in individuals with anorexia nervosa and can prolong QTc intervals, careful monitoring of serial electrocardiograms and serum potassium measurements is needed if anorexic patients are treated with ziprasidone [I]. Antianxiety agents used selectively before meals may be useful to reduce patients' anticipatory anxiety before eating [III], but because eating disorder patients may have a high propensity to become dependent on benzodiazepines, these medications should be used routinely only with considerable caution [I]. Pro-motility agents such as metoclopramide may be useful for bloating and abdominal pains that occur during refeeding in some patients [II]. Electroconvulsive therapy (ECT) has generally not been useful except in treating severe co-occurring disorders for which ECT is otherwise indicated [I].

      Although no specific hormone treatments or vitamin supplements have been shown to be helpful [I], supplemental calcium and vitamin D are often recommended [III]. Zinc supplements have been reported to foster weight gain in some patients, and patients may benefit from daily zinc-containing multivitamin tablets [II].

    1. Relapse Prevention

      Some data suggest that fluoxetine in dosages of up to 60 mg/day may help prevent relapse [II]. For patients receiving cognitive-behavioral therapy (CBT) after weight restoration, adding fluoxetine does not appear to confer additional benefits with respect to preventing relapse [II]. Antidepressants and other psychiatric medications may be used to treat specific, ongoing psychiatric symptoms of depressive, anxiety, obsessive-compulsive, and other comorbid disorders [I]. Clinicians should attend to the black box warnings in the package inserts relating to antidepressants and discuss the potential benefits and risks of antidepressant treatment with patients and families if such medications are to be prescribed [I].

    1. Chronic Anorexia Nervosa

      Although hormone replacement therapy (HRT) is frequently prescribed to improve bone mineral density in female patients, no good supporting evidence exists either in adults or in adolescents to demonstrate its efficacy [II]. Hormone therapy usually induces monthly menstrual bleeding, which may contribute to the patient's denial of the need to gain further weight [II]. Before estrogen is offered, it is recommended that efforts be made to increase weight and achieve resumption of normal menses [I]. There is no indication for the use of bisphosphonates such as alendronate in patients with anorexia nervosa [II]. Although there is no evidence that calcium or vitamin D supplementation reverses decreased bone mineral density, when calcium dietary intake is inadequate for growth and maintenance, calcium supplementation should be considered [I], and when the individual is not exposed to daily sunlight, vitamin D supplementation may be used [I]. However, large supplemental doses of vitamin D may be hazardous [I].


Back to top

Self-Help Resources For Anorexia Nervosa

Monitoring Your Progress

NOTE: When each of the following presentations finish; you must exit by manually closing its window in order to return to this webpage.

The Healthy Social Behavior Scale lists social behaviors that research has found to be associated with healthy social relationships. You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.

The Mental Health Scale lists behaviors and symptoms that research has found to be associated with mental health (or disorder). You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.

The Life Satisfaction Scale lists the survey questions often used to measure overall satisfaction with life. You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.

Life Satisfaction Scale (5-Minute Video)

The "Big 6" Dimensions of Mental Health

Research has shown that there are 5 major dimensions (the "Big 5 Factors" or Five-Factor Model) of personality disorders and other mental disorders.

This website uses these 5 major dimensions of human behavior (i.e., Agreeableness, Conscientiousness, Openness/Intellect, Extraversion/Sociability, and Emotional Stability) to describe all mental disorders. This website adds one more dimension, "Physical Health", to create the "Big 6" dimensions of mental health.

The behaviors of the "Five Factor Model of Personality" represent five adaptive functions that are vital to human survival. For example, when one individual approaches another, the individual must: (1) decide whether the other individual is friend or foe [ "Agreeableness" ], (2) decide if this represents safety or danger [ "Emotional Stability" ], (3) decide whether to approach or avoid the other individual [ "Extraversion/Sociability" ], (4) decide whether to proceed in a cautious or impulsive manner [ "Conscientiousness" ], and (5) learn from this experience [ "Openness/Intellect" ].

Desiderata (5-Minute Video)

The following "Morning Meditation" allows you to plan your day using these "Big 6" dimensions of mental health.

The following "Evening Meditation" allows you to review your progress on these "Big 6" dimensions of mental health.

Back to top

    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)

  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Economist in grim battle against deceptive scholarship

  • List of Predatory Journals and Publishers

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

  • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? Many medical research findings are statistically significant (with a p-value <0.05), but they are not clinically significant because the difference between the experimental and control groups is too small to be clinically relevant.

      For example, the effect of a new drug may be found to be 2% better than placebo. Statistically (if the sample size was large enough) this 2% difference could be statistically significant (with a p-value <0.05). However, clinicians would say that this 2% difference is not clinically significant (i.e., that it was too small to really make any difference).

      Statistically, the best way to test for clinical significance is to test for effect size (i.e., the size of the difference between two groups rather than confounding this with statistical probability).

      When the outcome of interest is a dichotomous variable, the commonly used measures of effect size include the odds ratio (OR), the relative risk (RR), and the risk difference (RD).

      When the outcome is a continuous variable, then the effect size is commonly represented as either the mean difference (MD) or the standardised mean difference (SMD) .

      The MD is the difference in the means of the treatment group and the control group, while the SMD is the MD divided by the standard deviation (SD), derived from either or both of the groups. Depending on how this SD is calculated, the SMD has several versions such, as Cohen's d, Glass's Δ, and Hedges' g.

        Clinical Significance: With Standard Mean Difference, the general rule of thumb is that a score of 0 to 0.25 indicates small to no effect, 0.25-0.50 a mild benefit, 0.5-1 a moderate to large benefit, and above 1.0 a huge benefit. It is a convention that a SMD of 0.5 or larger is a standard threshold for clinically meaningful benefit.

      The statistical summary should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention).

      In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size ( n ), mean ( M ) and standard deviation ( SD ) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean ( M ) is defined as "the sum ( Sum ) of the values of each observation divided by the total number ( n ) of observations". So: M = Sum / n . Thus: ( Sum ) = ( M ) multiplied by ( n ). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate ( M ) multiplied by ( n ). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean ( M ) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value , and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible.

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes

Research Topics

Anorexia Nervosa - Core Clinical Journals

Anorexia Nervosa - All Journals

Anorexia Nervosa - Review Articles - Core Clinical Journals

Anorexia Nervosa - Review Articles - All Journals

Anorexia Nervosa - Treatment - Core Clinical Journals

Anorexia Nervosa - Treatment - All Journals

Cochrane Review (The best evidence-based, standardized reviews available)

Some evidence of effectiveness:
  • Family therapy for those diagnosed with anorexia nervosa (2010) (Although there are a number of different forms of family therapy, the current review of 13 trials indicated that the therapy most often tested in trials is family based therapy. The trials included in the review had limitations in the reporting of trial conduct and meaningful outcomes. Overall there was some evidence to suggest family therapy may be effective compared to treatment as usual. However, there is not enough evidence to determine whether family therapy is effective compared to other psychological interventions for rates of remission. There were no differences in relapse rates, symptom scores, weight measures, or the number of drop outs between those treated with family therapy versus any other comparison group. Mortality was not measured or reported sufficiently to determine whether it is reduced for those treated with family therapy compared to other interventions. There were very little data about general or family functioning.)
No evidence of effectiveness:
  • Antidepressants for anorexia nervosa (2009) (The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy and acceptability of antidepressant treatment in acute AN. Seven small studies were identified; four placebo-controlled trials did not find evidence of efficacy of antidepressants in improving weight gain, eating disorder or associated symptoms, as well as differences in completion rates. Meta-analysis of data was not possible for most outcomes. However, major methodological limitations of these studies (e.g. insufficient power to detect differences) prevent from drawing definite conclusions or recommendations for antidepressant use in acute AN. )
Not yet possible to draw any definite conclusions due to insufficient evidence:
  • Outpatient psychotherapy for anorexic adults (2009) (This review aimed to assess evidence about the effects of outpatient psychotherapy on older adolescents and adults with anorexia nervosa. Although anorexia nervosa is a severe and disabling disorder, only seven trials were found. The trials used different types of psychotherapy. It was not possible to make firm conclusions about the therapies tested. Participants who did not receive psychotherapy (e.g. were in a waiting-list control group or who got 'treatment as usual') did poorly. In one study, all those in the control group who got only 'dietary advice' dropped out. There is an urgent need for multi-centre, large randomized controlled trials of commonly used psychotherapies in older adolescents and adults with anorexia nervosa.)

Back to top

Normal Distribution Of Human Attributes

Regression to the Mean (Or Why Scientific Experiments Require A Control Group)

The "Big 6" Dimensions of Mental Health

Research has shown that there are 5 major dimensions (the "Big 5 Factors" or Five-Factor Model) of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Five Factor Model of Personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", to create the "Big 6" dimensions of mental health.)

The behaviors of the "Five Factor Model of Personality" represent five adaptive functions that are vital to human survival. For example, when one individual approaches another, the individual must: (1) decide whether the other individual is friend or foe [ "Agreeableness" ], (2) decide if this represents safety or danger [ "Emotional Stability" ], (3) decide whether to approach or avoid the other individual [ "Extraversion/Sociability" ], (4) decide whether to proceed in a cautious or impulsive manner [ "Conscientiousness" ], and (5) learn from this experience [ "Openness/Intellect" ].

Which "Big 6" Dimensions of Mental Health Are Impaired in Anorexia Nervosa?

Being kind and honest.
Being unkind or dishonest.
Being diligent and self-disciplined.
Being distractible, impulsive, or undisciplined.
Showing good creativity, problem-solving, and learning ability
Impaired Intellect
Showing decreased creativity, problem-solving, or learning ability.
Being gregarious, assertive and enthusiastic.
Being detached, unassertive, and unenthusiastic.
Emotional Stability
Being emotionally stable and calm.
Emotional Distress
Being emotionally unstable/distressed.
      Emotional Distress
Physical Health
Being physically fit and healthy.
Physical Symptoms
Being physically unfit or ill.
      Physical Symptoms

The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder

The problems that are characteristic of this disorder are highlighted with this pink background color.


Description: Emotional Stability is synonymous with stability and calm. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. Individuals with high Emotional Stability are relatively tough, brave, and insensitive to physical pain, feel little worry even in stressful situations, and have little need to share their concerns with others. High Emotional Stability is associated with better: longevity, leadership, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate safety from danger.)
Descriptors: Calm, rarely angry, rarely depressed or moody, rarely anxious or embarrassed.
  • From Between facets and domains: 10 aspects of the Big Five
    • Stability:
      • Rarely get irritated
      • Keep my emotions under control
      • Rarely lose my composure
      • Am not easily annoyed
    • Calm:
      • Relaxed, handle stress well
      • Feel comfortable with myself
      • Am not embarrassed easily
      • Seldom feel blue
      • Rarely feel depressed
  • From International Personality Item Pool:
    • Remain calm under pressure
    • Rarely get irritated
    • Feel comfortable with myself
    • Relaxed most of the time
    • Am not embarrassed easily
Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
EMOTIONAL DISTRESS (Impaired Stability)
Description: Emotional Distress is synonymous with emotional volatility and negative emotion. Individuals with high emotional volatility are easily upset or angered. They often are very moody and emotionally labile. Individuals that have high negative emotion exhibit over-sensitivity to threat or stress. They exhibit excessive fear, anxiety, depression, or irritability.
ICD-11 Description: The core feature of the Emotional Distress (or Negative Affectivity) trait domain is the tendency to experience a broad range of negative emotions. Common manifestations of Emotional Distress include: experiencing a broad range of negative emotions with a frequency and intensity out of proportion to the situation; emotional lability and poor emotion regulation; negativistic attitudes; low self-esteem and self-confidence; and mistrustfulness.
Descriptors: Easily upset, angry, depressed, moody, anxious, embarrassed.
  • From Between facets and domains: 10 aspects of the Big Five
    • Emotional Instability:
      • Get angry or upset easily
      • Change my mood a lot
      • Am a person whose moods go up and down easily
      • Get easily agitated
      • Can be stirred up easily
    • Negative Emotion:
      • Worry a lot
      • Get nervous easily
      • Am filled with doubts about things
      • Feel threatened easily
      • Am easily discouraged
      • Become overwhelmed by events
      • Am afraid of many things
  • From International Personality Item Pool:
    • Panic easily
    • Get angry easily
    • Often feel blue
    • Worry about things
    • Am easily intimidated
Evolution: All animals have evolved a "fight or flight" response to threat to ensure their survival. Mammals went one step further and evolved a "fight, flight, or freeze" response to threat. In humans, this mammalian "freeze" response to threat involves inhibition of behavior in response to threat, punishment, and emotional distress. This threat response of "freezing", shutting down or passively avoiding is commonly seen in human anxiety or depression (e.g., freezing with fear or being immobilized by indecision, worry or depression).
Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
Screening Questions:
  • "I worry about almost everything."
  • "I get emotional easily, often for very little reason."
  • "I fear being alone in life more than anything else."
  • "I get stuck on one way of doing things, even when it’s clear it won’t work."
  • "I get irritated easily by all sorts of things."
Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Emotional Distress or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and emotional distress.
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
("Emotional Stability vs. Emotional Distress" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five) [More Information]
*MRI Research:
Testing predictions from personality neuroscience. Brain structure and the big five.

Back to top

Internet Mental Health © 1995-2019 Phillip W. Long, M.D.