Anorexia Nervosa, is a condition in which sufferers severely restrict food intake in an effort to control their weight and appearance. This can be due to hormonal imbalances, to deal with issues of self worth or trauma, or as a result of a distorted body image. Classified as both a physical and mental ailment, anorexia literally means “to lose appetite” and Nervosa means “anxiety. In essence, mental and emotional imbalances cause a distorted body image and compulsive dieting patterns which can be extremely debilitating and potentially life threatening.
Clinically, Anorexia is the intentional resistance to maintaining a healthy body weight, which is classified as no less than 15% reduction from standard weight/height charts. Individuals with Anorexia are classified as one of two types: those who restrict food consumption and those that although they may eat, especially in social settings, they have a habit of purging afterwards. It is also possible for an individual to maintain both behaviors. The eating habits of Anorexia are very often hidden from friends and loved ones, so as not to raise alarm and lose control. In addition, a person suffering with Anorexia may exercise manically in an attempt to attain a predetermined perception of beauty.
Statistics on Anorexia
Currently, Anorexia affects over eight million people in the United States, with a 10:1 ratio of female diagnosis compared to males. One in every 200 women suffers from Anorexia. However, it is believed that the number of cases is vastly underreported.
Also, in recent years, the average age of diagnosis with anorexia has lowered to ages 9 to 12, down from 13-17 in previous years. It is speculated the increasing influence of pop culture on young girls is partly responsible. Anorexia can be a deadly condition and in fact, in the 15-24 year old demographic, deaths from Anorexia are twelve times that of deaths from all other causes combined. Chronic eating disorders affect whites and minorities equally and are becoming a leading mental health concern internationally.
History of Anorexia
Although it has taken the spotlight in recent years, Anorexia Nervosa has been a recognized ailment for over one hundred years. The disease was formally named and documented in the late nineteenth century by Sir. William Gull, the private physician to Queen Victoria of England. However, there is also documentation from Doctor Richard Morton in the seventeenth century, as well as records of anorexic behavior by women of the Catholic Church under the pretext of continuous fasting in the quest for piety.
Signs and Symptoms of Anorexia
Anorexia is often a slowly progressing condition and often goes undetected. It may be labeled as “picky eating” or covered up by purging when alone. It is important to know the signs of Anorexia to provide early intervention to those suffering, as the condition can quickly spiral out of control.
Some of the behaviors exhibited by those suffering from Anorexia include:
- Obsessive fear of gaining weight
- Inaccurate self image
- Discards or hides food
- Likes to see others eat, but will refuse to eat themselves
- Eats, but purges immediately afterwards
- Uses laxatives, diet pills and vomiting to reduce appetite and expel food from the body
- Exercising fanatically, although often already trim
Some of the physical signs of Anorexia are:
- Rapid and noticeable weight loss
- Absence of three or more menstrual cycles because of hormonal disruption due to malnourishment
- Hair loss from nutritional deficiency
- Depression and isolation
- Dental erosion
- Neurological problems
- Organ damage
Difference from Other Eating Disorders
Anorexia is often confused with other eating disorders, due to some similarities. However, it is important to classify each case accurately to ensure the most appropriate treatment plan and chance of recovery. Below are other eating disorders and how they differ from Anorexia Nervosa:
Bulimia affects a slightly different demographic, in that it usually surfaces in the twenties instead of the preteen and teen years. Also, Bulimia varies greatly from Anorexia in that a major component of the illness is binge eating. Bulimia is characterized by ongoing sessions of binge eating, at least twice a week over a three month period. Individuals with Bulimia feel a compulsive, uncontrollable urge to eat in large amounts, however they feel extreme guilt which may lead to purging, excessive exercise or the use of laxatives to make up for the excess.
Another differencing factor between Anorexia and Bulimia is that Bulimics usually maintain a normal weight. They have periods of excess, which they counter by purging. Anorexics on the other hand literally starve themselves in an effort to change the composition of their body and their efforts become visible over time.
Other differences between Anorexia and Bulimia include:
There are also some differences in the serious health concerns that can develop as a result of each illness, which include:
Similarities between Anorexia and Bulimia include:
- Irregular heart patterns and potential heart failure
- A fixation on food to deal with mental or emotional stress
Binge Eating is another eating disorder and is perhaps more similar to Bulimia than Anorexia. In this disorder, the individual has an uncontrollable urge to frequently consume large quantities of food, often to the point of making themselves ill. This is usually a means to deal with feelings of inadequacy or emotional or mental trauma. However, Binge Eating usually exacerbates those feelings causing an increase in self loathing and shame due to the inability to control their eating habits. The major difference between Binge Eating and other eating disorders such as Anorexia and Bulimia is that the sufferer usually does not resort to purging or using laxatives to remove excess food from the body.
While Anorexia, Bulimia and Binge Eating are the most prevalent, there are various other eating disorders that are classified as “Atypical Eating Disorders”. This means that they are abnormal issues that affect a person’s relationship with food and require treatment to resolve. Examples of Atypical Eating Disorders include:
- Fear of choking
- Re-eating regurgitated food
- Weight loss or regurgitating without a discernable reason
- Physical pain when eating
- Heightened aversion to specific foods
- Food allergies that cannot be clinically confirmed
Causes of Anorexia
Anorexia is a complex disorder researchers are not yet able to definitively provide a concrete cause. Instead, it is known that there are a number of components and possible reasons for Anorexia, which varies case by case. Amongst the most common recognized factors are:
Psychological causes are a major factor in Anorexia.
Many sufferers have obsessive compulsive tendencies which feed the repeated cycle of starvation found in Anorexia. Also, feelings of imperfection and a need for approval are also powerful psychological drivers of eating disorders. A desire for control can also propel the disease out of control. If an individual feels at a loss to control parts of their life, Anorexia may be a way to exercise control over an element of their life, or as a passive aggressive means to fight back at a person or situation.
Societal and environmental pressures also contribute to the prevalence of Anorexia.
For young girls, there are a plethora of messages that are sent on a minute by minute basis that affect how they feel about themselves and their body. From peer pressure to be accepted in school, to the appearance of their favorite singers and stars, there are often unrealistic expectations placed in front of girls who are at a very impressionable stage in their lives.
It is important to understand that the media projects messages that support its agenda of promoting a specific norm or product. Often, this occurs by making the viewer feel inadequate and in need of the solution provided by the advertiser to become prettier, slimmer, or more likable. Discussing the intent behind advertising and many other forms of media and entertainment with young girls can help to inoculate them towards this.
Other societal factors that can lead to the development of Anorexia are pressure to achieve academically or artistically. A child may be in a rigorous training program for the ballet, where a petite figure is a necessity. Striving for this ideal could prompt an eating disorder, as could dealing with the stress of constant piano lessons, auditions and performances. It is important to ensure that children are involved in activities they find enjoyable and that an adult keeps a close eye for any problems that may arise.
Substance Abuse is a contributing factor to the development of eating disorders.
A correlation has been shown between the addictive components of alcohol and drug abuse and the repetition required to maintain an eating disorder. Studies have identified a genotype that is said to predispose one to addictive behaviors, which along with other factors may be one reason substance abuse and eating disorders often coexist in the same individual. It is important to note that substance abuse not only includes alcohol and illegal drugs, but also prescription drugs and cigarettes.
Abuse has also been shown to have a correlation to the development of Anorexia.
A study published in the British Journal of Psychiatry states that girls who experience sexual abuse prior to age 16, were twice as likely to develop an eating disorder later. This can be attributed to a need to exercise control, when conversely, at the time of the abuse, they were unable to control their circumstances. On the other hand, women who recall their childhood as happy and non-threatening possessed a better overall body image and were less likely to obsess over weight gain during their lives, including during pregnancy.
In addition to sexual abuse, other forms of abuse also impact the development of eating disorders such as Anorexia. These include, but are not limited to:
- Physical beatings and abuse
- Alcoholic parents or relatives
- Emotional cruelty
- Estranged or constantly bickering parents
Awareness of all of the risk factors of Anorexia allows parents, teachers and girls themselves to reduce the prevalence of this illness by tackling the causes, some very preventable, head on.
Diagnosing Anorexia requires a multi-pronged approach. Because the physical manifestations of Anorexia often stem from mental or emotional issues, psychological evaluation is a key component of reaching a diagnosis. However, there are clear steps that usually need to occur before an effective diagnosis can be given, which include the following:
Acknowledgement of an Eating Disorder
As with any addictive behavior, in order to move toward proper diagnosis and treatment, the patient must have a desire to accept help. With Anorexia, this can often be challenging, as it is by nature a secretive and isolating illness. Also, many sufferers do not equate their food restrictions to causing bodily harm. In addition, the mental and emotional gratification they may receive from their harmful actions usually outweigh a desire for intervention.
Due to this phenomenon, it is often a caregiver, family member or friend that coerces the individual to seek medical attention after witnessing their destructive behavior over time. The concerned party may have successfully convinced the patient that they have a problem, but more often than not, they agree to treatment quite reluctantly. For those who are aware that their behavior is abnormal, they may still be reluctant to seek help out of a sense of shame. It is important to be as supportive as possible in this early stage when the patient is extremely vulnerable.
In some cases, it may be someone outside of the patient’s family that recognizes that something is amiss. Often parents will classify disordered eating patterns as simply being “picky” or as a possible allergy to specific types of foods. The fact that avoiding certain foods on a long term basis can cause negative reactions when reintroduced can falsely confirm that theory. If a teacher, friend or neighbor identifies the problem, a candid conversation with the patient’s caregivers is needed.
Once it has been identified that there is a problem, medical advice should be promptly sought. Initially, this will consist of an interview to collect medical history, gauge the patient’s acceptance of their eating habits as abnormal and to ask a series of questions to understand the type and severity of the eating disorder. There are standard questionnaires that may be used when evaluating the patient, such as the Eating Disorders Examination, which the physician uses as a guide when interviewing the patient, the Eating Disorders Examination-Questionnaire, which the patient can fill out on her own and asks questions pertaining to habits in the last month. Also used is the SCOFF questionnaire, which is a wide range questionnaire for evaluating eating disorders. Questions focus on the patient’s deliberate attempts to control and restrict food and include:
- Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you succeeded)?
- Has thinking about food, eating or calories made it difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?
- Have you had a definite fear of losing control over eating?
- Have you had a definite fear that you might gain weight?
- Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling shape or weight?
- Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat, or to burn off calories?
- Over the past 28 days, how many times have you eaten in secret (ie, furtively)? Do not count episodes of binge eating.
- Has your weight influenced how you think about (judge) yourself as a person?
- How uncomfortable have you been seeing your body (for example, seeing your body in a mirror, in a shop window reflection, while undressing or when taking a bath or shower)?
- If a female, over the past 3-4 months, have you missed any menstrual periods?
The physician will use questions such as those above, in addition to a physical examination to diagnose Anorexia. One of the main physical criteria for diagnosing Anorexia is a failure to maintain at least 85% of the normal body weight for height. However some practitioners feel that this is not always a good gauge, as someone may be clearly anorexic, but has not gotten to below 85% body mass. Some additional physical signs that the physician will look for include:
- Digestive Issues
- Menstrual irregularities
- Overall weakness or tremors
- Moodiness and anxiety
- Heart palpitations
- Hair loss
In addition, the physician will most likely order blood work to assess body and organ and system function, which can be severely impaired with starvation and malnutrition. Some of the functions that may be checked include:
- Complete Blood Count (CBC)
- Anemia and Iron levels
- Dehydration and electrolyte balance
- Liver and Kidney function
- Thyroid performance
- Chest x-rays and heart scans
- Bone density examination
Once a thorough psychological and physical examination is conducted, a definitive Anorexia diagnosis can be made and a treatment plan can be initiated.
Treating Anorexia is a multifaceted discipline. An effective treatment will not only aim to restore lost weight, but also places considerable emphasis on psychological treatment and behavior modification, so as to reduce the chance of a relapse. Below is an overview of possible elements of a treatment plan for Anorexia.
Restoring physical health includes many components and various factors must be taken into consideration, including the length of the illness and the extent of bodily harm that has occurred. Some individuals will have engaged in anorexic behavior for an extended period of time and be experiencing severe symptoms, such as very low blood pressure, thoughts of suicide or extreme emaciation. In this case, the patient is often admitted to the hospital for treatment and observation. If very weak, the patient may be fed intravenously or through a feeding tube directly into the stomach until adequate strength is regained. In addition, the medical team will treat signs of dehydration, irregularities in the heartbeat and assess the patient’s overall organ function. Based on the outcomes of the tests, a detailed plan of treatment will be devised to address all of the issues identified. Once the patient is stronger, psychological therapy will be introduced as well.
In less severe cases, the patient will likely work with a physician, as well as a Registered Dietician, who will work to reintroduce healthy eating patterns and deconstruct myths surrounding food. In an effort to bolster weight gain, a specific dietary regimen will be devised, often with detailed menu plans and calorie requirements. Often a family member or other support person is designated to oversee the patient’s meals and ensure that they are consuming enough calories from the right foods. Often, the patient will also be prescribed vitamins and minerals to replenish what was lost during the starvation period. The patient will be required to check in with their medical team frequently, be weighed and likely submit a food journal for review.
Psychotherapy is a crucial element of treating anorexia, as most researchers believe the disorder stems from mental and emotional imbalances. If the patient is a sever case, or considered a danger to herself, the therapy may be held in an inpatient treatment center which requires the patient to meet certain milestones before release. In lesser cases, weekly visits to a therapist or group counseling sessions may suffice. Anorexia treatment also requires that the patient have a strong support system, so often counseling as a family unit is recommended as well. Below are the various types of therapy a patient might undergo:
One on one counseling is usually the first step in psychological treatment for Anorexia.
In the treatment sessions, the counselor will work to gain the trust of the patient and provide a safe space for open dialogue. A skilled therapist will be able to get the patient to open up and explore the reasons behind their food compulsions. Things that may come to light may be past or current abuse, a need for control, low self esteem, bullying and many other mentally or emotionally traumatic events and circumstances. Exploring and working through these issues can help the patient release the need for self destructive behavior.
If the patient has deep body image issues, they will receive intense counseling to erase the incorrect image of themselves in their minds eye. Often these patients see fat where there is none, and have very low self esteem. Depending on the severity of the misperception, talk therapy may suffice, or the therapist may have to employ more creative means of breaking this perception. Included in the overall therapy will be counseling on self esteem, media literacy to avoid negative advertising and methods to cope with critical peers or family members.
Group Therapy is an excellent option, especially for younger Anorexia patients.
It helps to see that there are others just like them who are struggling with the same issues and striving to overcome them. Also, the patient may likely see the other group members as not having obvious physical faults, which may cause them to rethink their own self image.
Group therapy sessions will include a facilitator that may ask participants to share their stories and feelings regarding food. Participants may be emboldened and comforted that there are familiar fears and struggles, similar to their own. Facilitators will allow patients to safely explore their need for control, instances of abuse and peer pressure that may be stimulating the eating disorder. It is important however, to make sure that any group sessions are facilitated by a qualified mental health professional.
Family Counseling is another effective option for treating Anorexia.
In battling this illness, support is an integral part of recovery. Parents, friends and mates can attend counseling with the patient to gain a better understanding of the illness, and what has triggered its development in the patient. Sessions may include conversations regarding family perceptions about food, pressure from parents and friends to be thin and beautiful and exploration of trauma or abuse that could have prompted the eating disorder.
In family counseling, the group will also be given coaching on how to support the patient in regaining weight and health. Menu plans may be given, as well as tools provided to maintain accountability for improvement. In the case of children and teens, parents will be tasked with monitoring food intake and weight gain. Additional counseling may be recommended to deal with severe trauma, such as sexual or physical abuse.
Body Image Counseling
Some patients with Anorexia may also suffer from Body Dysmorphic Disorder, which is a mental illness where they have a distorted and negative view of one or more parts of the body. This can cause the excessive rationing of food in Anorexia, in an effort to “fix” the perceived problem. In these instances, specific treatment is necessary to aid in healing. In addition to delving into whether past trauma or a fixation by someone on their body has contributed to BDD, the patient will also be evaluated for a serotonin deficiency, which can affect self perception. If so, medication will be prescribed to combat this, in addition to cognitive talk therapy to reprogram negative beliefs and behaviors.
Medication for Anorexia
There is no medication that resolves the many symptoms and contributing factors in Anorexia. However, certain drugs can help the patient cope and provide a clearer state of mind in order to successfully heal. As many cases of Anorexia stem from or contain an element of depression, anxiety, obsessive compulsive disorder, and low self esteem, antidepressants and other psychiatric medications may be prescribed as a part of the patient’s treatment plan. Also, as a common side affect of antidepressants is weight gain, some see them as having a particularly desirable affect for patients with Anorexia. Some commonly prescribed medications include:
Selective Serotonin Reuptake Inhibitors (SSRIs) are a class of medications that block the reabsorption of serotonin in the brain, which has an enhancement effect on mood. These are the most commonly prescribed depression medications and are said to have a comparatively smaller amount of side affects, relative to other antidepressants. Studies have shown that individuals that suffer from compulsive disorders such as Anorexia have distinctly different patterns in their neurotransmitters and neuroendocrine system, which can contribute to disease development. This class of medications includes Fluoxetine (Prozac), which is usually prescribed after the patient has regained some weight and semi-normal eating patterns. There have been mixed results when using this drug, but research has shown that SSRI medications have helped some patients avoid relapse into Anorexic behavior.
Commonly prescribed brand name SSRIs include: Celexa, Lexapro, Prozac, Serafem, Paxil, Paxeva, Zoloft and Sybmiax.
As with all medications, there are side affects associated with taking SSRIs. It is important to note that sexual side affects affect more than 50% of patients who take SSRIs regularly. Side affects may be somewhat lessened by taking a timed released version, which means that the medication from one pill is released over a daily or weekly period. Commonly reported side affects include:
- Weight gain
- Nausea and vomiting
- Dry mouth
- Erectile dysfunction and problems reaching climax
- Skin rash
- Insomnia or drowsiness
Younger patients –adolescents to young adults may experience suicidal thoughts and actions when taking antidepressants such as SSRIs. The FDA recommends that young patients be observed continuously for any signs that their depression is deepening or that they have thoughts or attempts to harm themselves, especially in the first few weeks of being on the medication.
The SSRI Prozac has specifically drawn attention in the media for inducing violent and suicidal behavior in children, with 50% more children experiencing this phenomenon, than those given a placebo. Prozac is specifically targeted to children and has previously been touted as the only SSRI on the market that was safe for children. However, recent studies have prompted the FDA to require cautionary labeling on packaging. Eli Lily and Co., the makers of Prozac have categorically denied that the drug causes suicide or violent tendencies, linking such behaviors to preexisting depression. There are however, many cases in which complainants have testified that they or their relatives only experienced such symptoms after being prescribed Prozac. In addition, personal injury firms are investigating Prozac on the basis that use in the first trimester of pregnancy can cause birth defects including congenital heart defects, cleft palate, down syndrome, Spina bifida and blindness. Other antidepressants may cause similar problems.
Tricyclic and Tetracyclic antidepressants are another class of medication used to treat Anorexia and have been in use since the 1950s. Primarily used to regulate Bipolar disorder, cyclic antidepressants inhibit the reabsorption of Seratonin, as well as Norepinephrine, which is a hormone in addition to a neurotransmitter. Increased levels of these hormones in the brain have observed to increase mood in patients with manic episodes and may be helpful for those with manic/depressive components to their Anorexia. Tricyclic and Tetracyclic antidepressants are prescribed less often than SSRIs such as Lexapro and Prozac, but may be used if symptoms do not abate with other medications.
Brand name cyclic medications come in liquid or injectable form and include: Tofranil, Tofranil-PM, Pamelor, Vivactil and Surmontil.
While these antidepressants have a positive affect on Seratonin and Norepinephrine neurotransmitters, they may inadvertently affect other chemical messengers in the brain as well. Because of this, there are possible side affects, including:
- Dry mouth
- Inability to urinate
- Low blood pressure
- Mental disorientation
- Sexual dysfunction
- Elevated heart rate
- Weight gain
Other Medical Concerns
Additionally, cyclic drugs are not recommended for use when pregnant or breastfeeding. The attending physician will recommend a less harmful antidepressant or non-drug therapy and work with the patient to wean off of the current drug.
Another possible problem with this class of drugs is Seratonin Syndrome. In this condition, there is an excess of serotonin in the brain (because its reabsorption is hindered by the drug). Individuals who take two or more serotonin enhancing drugs concurrently are at risk for this condition. Dangerous levels of Seratonin can prompt symptoms such as fever, rapid heartbeat, disorientation or confusion and loss of consciousness. Immediate medical attention is required in this case.
Cyclic antidepressants can also exacerbate some chronic health conditions and should be avoided in the case of prostate disease, heart conditions, thyroid malfunction, glaucoma and neurological disorders such as seizures. Cyclic drugs can also raise blood sugar and should be avoided by diabetics. For safety reasons, patients taking cyclic antidepressants should avoid using heavy machinery and perhaps driving, as they induce drowsiness. Lastly, it is important to receive regular blood tests, as high doses of cyclic drugs over time can cause serious health problems. This is one of the reasons this class is prescribed less than others.
Antipsychotic medications may be prescribed if the patient exhibits extremely distorted behavior, or poses a risk to themselves or others. This type of medication also increases appetite tremendously and may cause anxiety in the patient if they have not become comfortable with gaining weight. In addition to antipsychotic medication, the patient will also receive the nutritional and psychotherapy treatment common with Anorexic patients.
Anorexia and Pregnancy
Understandably, the presence of Anorexia during pregnancy is cause for special concern. Also labeled as “Pregorexia”, restricted eating patterns can cause harm to the fetus and mother ranging from mild to severe. Doctors recommend that a woman gains 25-35 pounds during pregnancy. Women who exhibit anorexic tendencies have a strong aversion to gaining weight during pregnancy. It is said that this constitutes approximately 5% of all pregnant women. While a pregnant woman with Anorexia may be loath to gain weight, she also often feels shame for harboring feelings that may possibly cause harm to her unborn child.
It is important for women to understand that a restrictive diet during pregnancy can lead to serious birth defects in the fetus. Possible side affects of Anorexia in pregnancy can include:
- Premature birth
- Low birth weight
- Poor weight gain
- Respiratory problems
- Increased risk of cesarean
Ideally, women with an identified case of Anorexia should seek treatment prior to trying to conceive. Long term anorexic behavior makes it hard to become pregnant, not only due to the possible absence of a menstrual cycle, but because of the depletion of the body’s nutritional resources. If a woman with Anorexia desires to become pregnancy, she should work with her doctor, as well as a fertility specialist and nutritionist to treat the illness and introduce a nutrition regimen that will foster a healthy pregnancy.
If a woman discovers that she is pregnant and is not currently being treated, it is imperative that she seek the counsel of a physician in order to avoid harming her child and herself. During pregnancy it is of the utmost importance to avoid purging, using diuretics and restricting calorie intake. Working with a medical team, including a trained therapist can help to ensure a healthy pregnancy.
In our appearance driven society, Anorexia is an extremely prevalent disease. Due to the associated shame and covert nature of the illness, it is estimated that only one in ten cases are referred to a physician for treatment. And while Anorexia is treatable, there is also a high relapse rate associated with this illness. Because of its roots in mental and emotional unease and abnormalities, the illness can be re-triggered by a wide number of factors.
Statistically, of individuals with Anorexia who seek treatment 60% maintain some symptoms of the illness or continue to experience full blown Anorexia. This is partially due to the fact that many cannot afford the long-term, intensive inpatient care they may require in order to effectively eradicate the illness. Also, up to 20% of Anorexics will die due to the illness, usually of suicide or cardiac failure.
While the outlook may seem bleak, it is possible to fully recover from Anorexia. Of those that do, the following traits are common:
- Admitting hunger
- Eliminating denial
- Closely following a treatment plan
- Resolution of emotional issues that impact food consumption
- Improved self esteem
- Relinquishing control over food consumption
- Acquiring a positive body image
- Ongoing support from family and friends
Support for Anorexia
There are many support groups for those dealing with Anorexia, as well as their family and friends. Below are some resources for those affected by this disease:
- National Eating Disorders Association: http://www.nationaleatingdisorders.org/
- National Association of Anorexia Nervosa and Associated Disorders: http://www.anad.org/
- Psych Central: http://psychcentral.com/resources/Eating_Disorders/Support_Groups/
- Daily Strength: http://www.dailystrength.org/c/Eating-Disorders/support-group
- SupportGroups.com: http://anorexia.supportgroups.com/
- Eating Disorders Online: http://www.eatingdisordersonline.com/
- National Alliance on Mental Illnesses. Mental Illness-Anorexia: http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagement/ContentDisplay.cfm&ContentID=7409
- Journal of Social Issues. The Media’s Influence on Body Image Disturbance and Eating Disorders:
- Mirror Mirror. Anorexia Statistics: http://www.mirror-mirror.org/anorexia-statistics.htm
- BBC News. Abuse Triggers Eating Disorders: http://news.bbc.co.uk/2/hi/health/4417938.stm
- Cognitive Behavior Therapy and Eating Disorders. Eating Disorder Examination Questionaire
- University of Maryland Medical Center. Eating Disorders-Diagnosis
- John Hopkins Medicine. Frequently Asked Questions about Eating Disorders
- The Healthy Place. Co-Morbid Substance Abuse and Eating Disorders Statistics
- CNN Health. Papers Indicate Firm new of Possible Prozac Suicide Risk
- The Daily Express. Is Prozac the Trigger for Suicide?: http://www.antidepressantsfacts.com/1999-09-29-Lilly-block-research.htm
- USA Today. Prozac Linked to Child Suicide Risk: http://www.usatoday.com/news/health/2004-09-13-prozac_x.htm
- Mayo Clinic. Anorexia Nervosa: http://www.mayoclinic.com/health/anorexia/DS00606
- Mayo Clinic. Depression- Selective Seratonin Reuptake Inhibitors: http://www.mayoclinic.com/health/ssris/MH00066
- Mayo Clinic. Tricyclic Antidepressants and Tetracyclic Antidepressants: http://www.mayoclinic.com/health/antidepressants/MH00071
- The Victorian. Pregorexia-When Pregnant Women or New Mothers have Anorexia
- American Pregnancy Association. Eating Disorders During Pregnancy
- Cleveland Clinic. Eating Disorders
- University of Michigan. Media Influence Eating Disorders: http://ur.umich.edu/9798/Oct22_97/media.htm