Anorexia nervosa: symptoms and treatment

Anorexia nervosa is a serious mental health condition that causes a person to severely limit food intake, often leading to dangerously low body weight, medical complications, and emotional distress. According to the National Institute of Mental Health, it has the highest mortality rate of any psychiatric disorder.¹ It is also treatable. With appropriate care, recovery is possible at any age and any stage of illness.

This page explains how anorexia is recognized, why early treatment matters, what evidence-based care looks like, and how to find the right level of care. It is written for parents and family members who are trying to figure out the next step, and for adults trying to understand their own experience.

What is anorexia nervosa?

Anorexia nervosa is one of three primary eating disorders defined in the DSM-5, alongside bulimia nervosa and binge eating disorder. It is characterized by three core features: restriction of food intake leading to significantly low body weight, an intense fear of gaining weight or becoming fat, and a disturbance in the way one's body weight or shape is experienced.²

The DSM-5 recognizes two subtypes. The restricting type involves food restriction, fasting, and excessive exercise without regular binge eating or purging. The binge-eating/purging type involves cycles of restriction with episodes of binge eating, self-induced vomiting, or misuse of laxatives, diuretics, or enemas. Both subtypes share the same core diagnostic criteria and carry serious medical risk.

Anorexia affects people of all genders, ages, body sizes, and ethnic backgrounds. The widespread image of a young, very thin, white woman is incomplete and contributes to under-diagnosis. The condition occurs in men, in people of color, in middle-aged and older adults, in people whose body weight appears in the normal or higher range, and in people whose eating disorder began later in life. Lifetime prevalence is estimated at roughly 0.6 percent in women and 0.3 percent in men in the United States, with growing recognition that these figures likely undercount cases that do not match the stereotype.³

A presentation called atypical anorexia describes someone who meets every diagnostic criterion for anorexia nervosa except low body weight. Atypical anorexia is medically just as serious as typical anorexia, can produce the same complications, and requires the same treatment. The body weight number does not determine whether a person needs care.

A hallmark of anorexia is limited insight, sometimes called anosognosia, meaning a lack of awareness that anything is wrong. Many people with restrictive eating do not experience the behavior as a problem even as it becomes medically dangerous, so the concern is usually first raised by a friend or family member, or it surfaces when medical complications appear that will not resolve until the anorexia itself is treated.

Signs and symptoms

Anorexia presents through a combination of behavioral, physical, and emotional changes. Symptoms develop gradually in many people, which can make them easy to miss in the early months. Not every person shows every symptom, and the absence of one sign does not rule out the condition.

Behavioral signs

• Restricting food intake, skipping meals, or eating very small portions
• Strict rules about what, when, or how much to eat
• Rituals around eating: cutting food into tiny pieces, eating very slowly, rearranging food on the plate
• Excessive or compulsive exercise, often continued through illness or injury
• Withdrawal from meals with family or friends, eating alone, hiding food
• Frequent weighing, mirror-checking, or measuring of the body
• Wearing layered or oversized clothing, often regardless of temperature
• Preoccupation with food: cooking elaborate meals for others while not eating, reading recipes, calorie research

Physical signs

• Significant weight loss, slowed growth in adolescents, or failure to gain weight during expected growth periods
• Persistent fatigue, weakness, or low energy
• Dizziness, fainting, or feeling cold all the time
• Menstrual changes in those who menstruate: missed, irregular, or delayed periods
• Hair thinning on the scalp; soft, fine hair (lanugo) on the body
• Dry skin, brittle nails, slow wound healing
• Constipation, bloating, abdominal pain, or other gastrointestinal complaints

Emotional and cognitive signs

• Distorted body image, seeing oneself as larger than reality
• Intense fear of weight gain that does not lessen as weight decreases
• Anxiety, especially around food, mealtimes, or social eating
• Depression, irritability, or emotional flatness
• Difficulty concentrating, memory complaints, or slowed thinking
• Increased perfectionism, rigidity, or need for control
• Social withdrawal from activities, friends, or family

In adolescents, symptoms can also include school avoidance, academic decline, conflict with parents around food, or rapid changes in personality. In adults, symptoms can be masked by professional functioning or by the perception that the person is "just very disciplined."

Health complications

Anorexia affects nearly every organ system in the body. The longer the condition is untreated, the higher the risk of serious complications, including some that do not fully reverse.

Cardiac complications are among the most dangerous. Malnutrition reduces heart muscle mass, slows the heart rate (bradycardia), lowers blood pressure (hypotension), and disrupts the heart's electrical conduction. These changes increase the risk of arrhythmia, including potentially fatal arrhythmia. Sudden cardiac death is the leading medical cause of mortality in anorexia.⁴

Electrolyte imbalances result from restriction, vomiting, laxative use, and excessive exercise. Low potassium, low sodium, and low phosphorus can cause cardiac arrhythmias, seizures, and muscle weakness. Phosphorus depletion is particularly dangerous during the early days of refeeding, a complication called refeeding syndrome that requires careful medical monitoring.

Bone density loss begins early in anorexia and is partially or fully irreversible in many people. Adolescent and young adult women with anorexia can lose 2 to 6 percent of their bone density per year of illness, increasing lifetime fracture risk and the risk of early-onset osteoporosis. Men with anorexia experience similar bone effects.

Endocrine disruption affects multiple hormone systems. Malnutrition can suppress the hormones that regulate the menstrual cycle, which may cause periods to stop or become irregular. This does not happen to everyone, and loss of menstruation is no longer part of the diagnostic criteria, so a normal cycle does not mean a person is medically safe. Fertility is often affected during illness and may take time to recover after weight restoration. Growth in adolescents can be permanently stunted if anorexia occurs during puberty. Thyroid function slows, which contributes to fatigue and cold intolerance.

Gastrointestinal complications are common and often distressing for the patient. Delayed gastric emptying, constipation, reflux, and bloating result from the body's slowed metabolism. These symptoms typically improve with consistent nutritional rehabilitation, though they can persist and require their own treatment.

Mortality. Anorexia carries the highest mortality rate of any psychiatric disorder, with cardiac complications and suicide as the leading causes. Crude mortality rates from longitudinal studies range from approximately 4 to 6 percent across multi-decade follow-up.⁴ Earlier intervention substantially improves survival and recovery outcomes.

Treatment options

Effective treatment for anorexia is multidisciplinary. It typically combines medical care, nutritional rehabilitation, and psychotherapy, with the specific approach matched to the person's age, medical stability, severity of illness, and any co-occurring conditions like depression, anxiety, or trauma.

The first decision is often medical, not psychological. A person who is medically unstable (significant cardiac changes, severe electrolyte abnormalities, severe weight loss, or acute risk of refeeding syndrome) needs medical stabilization before or alongside any other treatment, often in an inpatient hospital or residential program with 24-hour medical monitoring.

Once medical stability is established, the therapies with the strongest research support for anorexia are:

• Family-Based Treatment (FBT), also called the Maudsley approach, has the strongest research support for children and adolescents, and is increasingly used with young adults who have involved caregivers.⁵ In the early phase, FBT puts caregivers in charge of meals and refeeding, then gradually returns control over eating to the person as recovery progresses. Treatment typically runs 6 to 12 months. FBT outperforms individual therapy for most adolescents and is a recommended first-line treatment in clinical guidelines.

• Cognitive Behavioral Therapy for Eating Disorders (CBT-E) is an enhanced form of CBT designed specifically for adults and older adolescents with eating disorders.⁶ CBT-E addresses the cognitive and behavioral patterns that maintain the eating disorder, including overvaluation of weight and shape, dietary restriction, and the cycle of binge-purge behaviors when present. Treatment typically runs 20 to 40 weeks. Formal CBT-E training is still limited in the United States, so it is offered less often here than its research base might suggest.

• Specialist Supportive Clinical Management (SSCM) combines clinical case management with supportive psychotherapy and has shown comparable effectiveness to CBT-E for adults with anorexia in some clinical trials. Like CBT-E, it is more common in research and outside the United States than in routine US programs.

In practice, many US programs draw on therapies that are widely available here: dialectical behavior therapy (DBT) for emotion regulation, acceptance and commitment therapy (ACT), standard cognitive behavioral therapy (CBT), and exposure and response prevention (ERP) for the anxiety and rituals that drive restrictive eating. These work best alongside nutritional rehabilitation and weight restoration, not as a substitute for them.

Family therapy is a cornerstone of eating disorder care and is offered by most strong programs for adults as well as adolescents. Unlike FBT, which puts caregivers in charge of refeeding a younger patient, family therapy here means working with family or chosen support people so they can support recovery rather than the eating disorder.

Nutritional rehabilitation is foundational to all anorexia treatment. A registered dietitian, often one with eating disorder specialty credentials such as CEDS-S, develops an individualized meal plan and works with the patient (and the family, in adolescent treatment) to gradually restore healthy eating patterns and weight. Supervised meal support, where staff or trained caregivers sit with the person during and after eating, is a core part of care at every level above outpatient, because mealtimes are when eating disorder behaviors are hardest to manage alone. Refeeding is monitored closely in the early weeks to prevent refeeding syndrome.

Pharmacotherapy plays a limited role in anorexia treatment. No medication has been shown to consistently treat the core symptoms of anorexia in adults.⁷ Medications can be useful for treating co-occurring depression, anxiety, or obsessive-compulsive symptoms, particularly after some weight has been restored, when the brain can respond more reliably to medication.

Treatment of co-occurring conditions is often essential. Approximately half of people with anorexia also meet criteria for an anxiety disorder, depression, or obsessive-compulsive disorder.³ Treatment plans that address only the eating disorder without addressing co-occurring conditions are more likely to fail. Trauma-informed care matters when post-traumatic stress is part of the clinical picture.

Outcomes. With appropriate treatment, roughly half of people with anorexia achieve full recovery and another 20 to 30 percent improve significantly, with a smaller group experiencing chronic illness. Earlier treatment improves the odds, and recovery is possible at any age and any stage.⁸

Finding the right level of care

Treatment intensity ranges from outpatient sessions a few times a month to 24-hour residential or inpatient care. The right level of care depends on medical stability, severity of behaviors, history of prior treatment, home environment, and the presence of co-occurring conditions. A clinical assessment is the only reliable way to match a person to the appropriate level. Most treatment programs offer a phone-based assessment as part of admissions.

The continuum of care, from highest to lowest intensity:

• Inpatient hospitalization is hospital-based care for acute medical or psychiatric danger, with round-the-clock monitoring. Length of stay is typically days to a few weeks, focused on medical stabilization rather than long-term recovery.

• Medical stabilization programs provide the most intensive medical care for people who are too medically acute for other programs, including complex refeeding. They typically run for 1 to 4 weeks and serve as a bridge to longer-term treatment.

• Residential treatment offers 24-hour care in a non-hospital setting, with a typical stay of 30 to 90 days. Used when outpatient or partial-hospitalization care is not sufficient to interrupt eating disorder behaviors, or when the home environment is making recovery harder.

• Partial hospitalization (PHP) runs 5 to 6 days a week for 6 to 8 hours a day. The patient lives at home and returns to the program during the day for structured care, supervised meals, and therapy. Typical length 4 to 12 weeks.

• Intensive outpatient (IOP) is 9 to 15 hours per week of treatment, structured to fit around work or school. Often used as a step-down from PHP or as a step-up from outpatient care when a more intensive structure is needed.

• Outpatient therapy involves weekly sessions with a therapist, often combined with weekly sessions with a dietitian and periodic medical follow-up. Appropriate for people who are medically stable, have a supportive home environment, and have eating disorder behaviors at a frequency that can be addressed with weekly support.

Most people move through more than one level of care during recovery. A common path is residential to PHP to IOP to outpatient, with each step lower in intensity. The full continuum typically lasts 6 to 12 months from acute care through outpatient maintenance, though longer treatment is often clinically indicated for entrenched cases. Most major commercial plans cover medically necessary treatment, though coverage and pre-authorization rules vary by plan and level of care; see our insurance guides.

For families

Watching someone you love develop anorexia is hard, and many families feel they should be able to fix it themselves. Anorexia is a serious mental illness, not a phase or a choice, and it usually does not resolve without specialty care. Reaching out for an assessment is not an overreaction.

A guide for parents and partners on how to start the conversation, what to expect from the first call to a treatment program, and how to support a loved one through care: read our family guide.