An estimated 1.6 million people suffer from an eating disorder in the UK– 6.4% of the adult population, and the prevalence is even higher amongst athletes.

Key Features of Anorexia Nervosa: Symptoms, Causes and Treatment

Eating disorders are popular topics in the media and are frequently the focus of television programmes such as Supersize vs. Superskinny and Dana: the 8 year old anorexic (Clifford, 2008). Widespread interest in anorexia nervosa can be understood by the bewilderment of how any human could starve themself and lose the instinct to keep themselves alive. With the highest mortality rate of any psychiatric disorder, lack of understanding of anorexia extends to health professionals. One hundred and forty years after the disorder was first established as a ‘nervous loss of appetite’, biomedicine still fails to adequately define, explain or cure anorexia.

Whilst anorexia remains mysterious, the criteria for a diagnosis are stringent: refusal to maintain normal body weight (<85% expected weight), fear of gaining weight, disturbance in self-evaluation of weight or shape, and amenorrhea. The significant revision of criteria for the next version of the Diagnostic and Statistical Manual of Mental Disordersdemonstrates how current criteria are totally inadequate. The removal of amenorrhea as a criterion from DSM-5 highlights the increase in ‘manorexia’. Whilst the female to male prevalence of anorexia is 11 to one there has been a 66% rise in male hospital admissions for eating disorders in the last decade.

Other behavioural, cognitive and emotional signs of anorexia include missing meals, excessive exercise and perfectionism, some of which have been proposed as alternative diagnostic criteria.Recent research has identified auditory hallucinations, impaired ‘set-shifting’, and psychological inflexibility as additional symptoms. However, considerable underlying heterogeneity means it is difficult to reduce anorexia to a psychiatric tick list which would identify all those suffering.

Unfortunately, DSM-IV criteria fail to identify the majority of those affected by anorexia. Whilst sufferers may display a buffet of disordered eating symptoms, many cannot access treatment because they do not meet the diagnostic criteria. For example, West Sussex Family Eating Disorder Service does not treat sufferers when the diagnosis of anorexia is unclear.

The cause of anorexia has been attributed to everything from genes, low birth weight, and abnormal neurotransmitters, to insecure attachment, unresolved trauma, and media ideals. Whilst professionals accept that there is no single cause of anorexia, this medicalisation has resulted in an assumed underlying pathology. This isolates those with anorexia as abnormal, disregards personal experiences, and ultimately prevents sufferers from recovering as social and moral individuals. Instead those with anorexia are treated as cognitive cripples fixable with drugs and Foucauldian-powered regimes.

Treatment programmes for anorexia are largely unsuccessful. Clinicians’ disregard for the uniqueness of each individual’s suffering has resulted in treatment plans which may actually replicate conditions that cause the disorder.

Anorexia Nervosa in Sport 

Constructing anorexia as a biocultural disease eradicates the Cartesian dualism of modern medicine. Anorexia as a social matter is supported by the increased prevalence of anorexia among athletes. The performance, ascetic and virtuous dispositions often found in those with anorexia, combined with aesthetic, aerodynamic and weight-categorised pressures, may prime athletes for anorexia.

Despite the high prevalence, identifying anorexia is even more challenging in a sporting environment with symptoms being dismissed as a benign form of the clinical syndrome. The similarities between the traits of ‘good athletes’ and those with anorexia, and the reinforcement of dieting by coaches, further complicates diagnosis and treatment.

Questionnaires, such as the EDE-Q, can been used to identify anorexia among athletes. Whilst viewed as valid instruments to assess eating disorder psychopathology, self-report measures are subject to social desirability bias and faking good. Denial may also be used by athletes in an attempt to disguise the severity of their suffering.

It should be noted that psychometric measures of anorexia predominantly include negative self-statements (e.g. ‘I feel guilty after eating’) which may foster self-criticism – a key predictor of anorexia. This can also inspire athletes with anorexia to live up to the symptoms of their diagnosis. However, positive psychology measures have been developed (e.g. Body Appreciation Scale) focusing on sufferers’ strengths rather than their symptoms.

Instead of relying on questionnaires, coaches need to be aware of any disordered eating behaviour which could indicate anorexia, as well as athletes’ emotional and psychological state. Knowledge of the female athlete triad is especially important for anyone working with young women in sport.

Reducing the taboo around eating disorders in sport is crucial in preventing athletes suffering from anorexia from getting abandoned.  Educating coaches and parents on preventative strategies is key in reducing risk factors and encouraging sufferers to seek treatment.

Preventative strategies include:

  • Advocating health and wellbeing
  • De-emphasizing body weight
  • Using role models with healthy body weight
  • Referring athletes with disordered eating to a specialist
  • Dispelling myths that ‘thinner is better’
  • Make disordered eating a health and safety issue rather than a coaching issue

Practical Challenges of Anorexia Nervosa in Sport and Appropriate Support Interventions 

Recovery from anorexia is challenging, especially for athletes. Because it is considered normal for an athlete to pay meticulous attention to their diet and weight, anorexic behaviours may be justified to family as part of the athlete’s training programme, preventing early intervention and delaying recovery.

Sport Psychologists play a key role in identification of anorexia, but a referral should be made to specialists (ideally with the athlete’s consent) so the athlete has the appropriate support from a multidisciplinary team, which can provide nutritional support, psychological therapies and medical check-ups. Whilst some clinicians advise that athletes can only train if they comply with treatment, whether sport withdrawal is necessary for recovery in anorexia is debated. Resource intensive treatment does not necessarily improve prognosis of anorexia, therefore empowering the athlete to take control of their own recovery, with trusted support and expert advice, may be more effective unless their physical health is at risk.

During the athlete’s recovery, coaches need to prioritise the person over their performance, and treatment teams need to see the sufferers’ strengths not just their symptoms. An athlete’s recovery should not be seen purely as getting rid of problems, but in seeing beyond the anorexia to the passions that give meaning to their life. Therefore continuing to train can be helpful for athletes in recovery, encouraging weight restoration, reducing body dissatisfaction, and helping athletes to develop a positive sense of identity.

Athletic participation can also be protective against the development of anorexia, especially in non-elite sport. Adapted Physical Activity, dance therapy, and yoga can be usefully integrated into treatment programmes for anorexia. Therefore, exercise not does not necessarily increase the risk of anorexia, but can actually be a tool for healing.

In conclusion, anorexia is mysterious and unpredictable. Its diagnostic criteria are currently being revised.  Despite the high prevalence of anorexia in elite athletes, the sporting environment and pressures makes it difficult to identify and treat. There is no one-size-fits-all treatment for athletes with anorexia. A holistic approach, offering, psychological, emotional and spiritual support is essential in helping the athlete to realise that the anorexia need not starve them of their sporting hopes, but that they can be strengthened through suffering. Empowering the athlete to apply their sporting discipline and anorexic asceticism to recovery allows them to use their struggles to reconstruct life’s meaning, to transform fear into faith, and to thrive.