anorexia

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Anorexia nervosa is a serious mental illness. Those affected lose weight rapidly through pathological dieting - up to life-threatening conditions. A distorted body image is also typical: the patients find themselves too fat, although they are already severely underweight. Read here how to recognize anorexia, what causes it and how to treat it.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. F50

Brief overview

• Description: mental illness, eating disorder with an addiction-like character, severe, sometimes life-threatening weight loss due to radical diet and / or exercise, distorted body image
• Symptoms: massive weight loss, underweight, urge to starve, need to control, fear of weight gain, thoughts revolve around weight and nutrition, physical deficiency symptoms, lack of insight into the disease
• Causes: disturbed stress processing, genetic factors, disturbed messenger metabolism, strong need for control, high performance demands, western ideal of beauty
• Diagnosis: severe underweight, self-induced weight loss, body scheme disorder, disturbed hormone balance
• Treatment: mostly inpatient therapy, normalization of weight and eating behavior, behavioral individual and group sessions, family therapy
• Prognosis: Around 50 percent of those affected largely overcome the eating disorder with therapeutic help. The shorter the duration of anorexia or the milder the disease, the better the prognosis. Fatal outcome in around 10 percent of those affected.

Anorexia: description

Patients with anorexia (anorexia or anorexia nervosa) have the pathological desire to keep reducing their body weight. Getting started with the disease is often a diet. Over time, thoughts about their own body weight increasingly determine the entire everyday life of those affected. Even though they are only skin and bones, they feel too fat and want to keep losing weight.

Anorexia, along with bulimia and binge eating disorder, is one of the eating disorders. The severe weight loss is the most noticeable symptom of anorexia. Ultimately, however, it is only the externally visible sign of a profound mental disturbance. To cure the disease, it is not enough just to eat again.

Addictive urge

The disease has an addiction-like character: the urge to starve is almost irresistible for the patient. The special kick is to have the greatest possible control over your needs and your body. This is hardly understandable for outsiders.

Anorexic people (anorectic people) also have no insight into the disease for a long time. They find it difficult to admit to themselves that they have problematic eating habits. They therefore often resist therapy.

Anorexia nervosa is a serious mental illness. Some of those affected die from malnutrition or suicide.

Who Does Anorexia Affect?

Anorexia usually first occurs in early adolescence. However, the age limit is increasingly shifting downwards. In the meantime, children are already suffering from it. Most anorexics are female and between 15 and 25 years old. But boys and men are also developing anorexia more and more frequently.

• Treat anorexia early

  Three questions for

  

  Dr. med. Robert Doerr,
  Specialist in psychiatry, psychotherapy
• 1

  Why is it difficult for anorexics to realize that they are sick?

  

  Dr. med. Robert Doerr

  In addition to massive weight loss, anorexia usually also leads to distorted body perception. Affected people perceive themselves as too fat, even though they are actually significantly underweight. This is called "body schema disorder" and can be life-threatening. Therefore, the earlier you receive treatment, the better your prognosis!

• 2

  What warning signs should relatives watch out for?

  

  Dr. med. Robert Doerr

  There are many indications: dissatisfaction with weight, the false belief that you are too fat, pronounced weight loss. Affected people deal intensively with the topic of food, like to cook for others, but never eat with them. Meals are skipped or taken alone at certain times. A strong urge to move around and avoiding certain foods are also warning signs.

• 3

  What can be done to prevent relapse?

  

  Dr. med. Robert Doerr

  The risk of anorexia relapse is actually very high. Therefore, even after completing a treatment, check continuously whether you are continuing to pursue your previously formulated goals or whether there have been relapses in some areas (e.g. eating behavior, weight, exercise). It is also good if you talk to a professional helper at regular intervals.

• 

  Dr. med. Robert Doerr,
  Specialist in psychiatry, psychotherapy

  Dr. med. Robert Doerr is chief physician at the Schön Klinik Berchtesgadener Land in the field of psychosomatic medicine.

Anorexia: symptoms

The main symptoms of anorexia are considerable self-induced weight loss, a pronounced fear of gaining weight despite already being underweight and a distorted perception of one's own body.

Since malnutrition affects many important physical functions, numerous physical (physical) complaints also occur.

Weight loss

The strong weight loss is the most noticeable sign of anorexia. Those affected avoid high-calorie foods and study the contents of foods in detail. In some cases, anorexic people reduce their meals so much that they only consume water at times.

Some people try to lose weight through excessive exercise. Some also take laxatives or diuretics to help them lose weight.

The desire for more and more weight loss and constant weight control will at some point determine the entire thinking and everyday life of those affected. They regard stagnation in weight or even weight gain as severe setbacks, whereupon they intensify their efforts.

Underweight

Anorexic people lose an average of 40 to 50 percent of their original weight. According to the clinical diagnostic guidelines, a body mass index (BMI) of 17.5 or more is a sign of anorexia in adults. That is 15 percent less than normal weight. Different limit values ​​apply to children and adolescents, as their body mass index cannot be calculated using the usual formula.

If you openly talk to those affected about their thinness, they often react irritably.

Cachexia: Life-threatening underweight

If the emaciation is massive, one speaks of cachexia. With such a pronounced underweight, the body's fat reserves are largely depleted and larger amounts of muscle mass have already been lost. The body is then extremely weak - a life-threatening condition.

Cachexia is visible from the outside at this stage. The bone contours stand out strongly, the eyes are deep, the cheeks appear hollow. Patients usually try to hide these typical signs of anorexia. They wear clothes in several layers that cover the body as much as possible.

Distorted body image

Anorexics have a distorted perception of their own body. Despite their underweight, many consider themselves fat. Those skilled in the art refer to this phenomenon as a body schema disorder. It is difficult for outsiders to understand that those affected actually feel that they are overweight when they look in the mirror.

Neither assurances from others nor objective weight measures such as the BMI can convince anorexics of their factual underweight. Body schema disorder is a serious problem that can be overcome over an extended period of time with professional help alone.

Distorted body image in anorexia

People who suffer from anorexia often have a distorted perception of their own body. This distorted body image, also known as a body schema disorder, causes those affected to see themselves in the mirror as overweight or too fat, even though they are not.

Constant preoccupation with your own weight

A very characteristic sign of anorexia is the constant preoccupation with your own weight and diet. Anorexic people are terrified of gaining weight and being too fat. That doesn't necessarily mean they will lose their appetite. Rather, all of their thinking revolves around food and diets. You deal intensively with recipes and enjoy cooking for others.

Constant control

Affected people know the calorie content of most foods and pay close attention to how many calories they ingest from food each day. Anorexia is ultimately an attempt to control yourself and your body.

Enduring and overcoming the feeling of hunger is a success for anorexics. Eating food becomes torture at some point, as eating means loss of control and a guilty conscience for them.

Starving as a normal state

Anorexics do not feel that their weight is too low. Hunger becomes an addiction and the reduction of food becomes a kind of race with oneself. The feeling of hunger becomes the normal state, the feeling of satiety becomes unpleasant. At some point the weight loss is so threatening that patients have to be admitted to a clinic.

Excessive performance orientation

Anorexics are noticeably often intelligent and very performance-oriented people who try to complete all tasks perfectly. They are particularly ambitious when doing sports or at school. However, they are withdrawing more and more from social life. This self-desired social isolation is a serious warning sign.

Mood swings and depression

Anorexics also very often suffer from severe mood swings and depressive moods. These anorexia symptoms can result from malnutrition and constant internal pressure to lose weight. Mental disorders that often occur at the same time as anorexia are depression, anxiety, obsessive-compulsive and addictive disorders, and personality disorders.

Physical (somatic) anorexia symptoms

Anorexia damages the entire body. Due to malnutrition, he reduces his energy consumption to the essentials. All organ systems are affected. This explains the multitude of possible physical consequences of anorexia:

• Slow heartbeat (bradycardia) and irregular heartbeat
• low blood pressure (hypotension)
• Constipation (constipation)
• Freezing and hypothermia (hypothermia)
• Lack of red and white blood cells and platelets (pancytopenia)
• dry skin
• Hair loss
• downy hair (lanugo hair) instead of normal body hair
• in girls / women: cessation of menstruation (amenorrhea), infertility
• in boys / men: problems with potency
• sexual listlessness (loss of libido)
• Disturbance of the electrolyte and vitamin balance
• Decrease in bone mass (osteoporosis)
• Kidney dysfunction
• Liver dysfunction
• Difficulty concentrating
• Developmental Delay in Children and Adolescents
• Brain wasting (brain atrophy)

Hormonal disorders

The fact that being severely underweight in girls and women leads to the cessation of menstrual periods (amenorrhea) and loss of sexual desire (loss of libido) is due to the fact that anorexia disrupts the hormonal balance: As a result of malnutrition, the body can no longer adequately produce certain hormones, which is less affects the menstrual cycle, among other things.

This can make sense from an evolutionary perspective: a woman with anorexia would not be able to carry a child to term, which is why the body prevents pregnancy due to the lack of sex hormones.

Also due to hormonal disorders, boys and men with anorexia also suffer from a loss of libido and often also of potency.

Anorexia: causes and risk factors

So far, there have only been guesses as to the exact causes of anorexia. What is certain, however, is that the disease anorexia nervosa cannot be traced back to a single trigger, but that there are many reasons for anorexia.

Biological and psychological as well as sociocultural factors contribute to the development of anorexia, and these mutually reinforce one another.

Biological factors

Disturbed stress processing

Newer scientific hypotheses assume a disturbed stress processing as the central cause of anorexia. Such disorders can have genetic causes, can already be created by influences in the womb, or they can be shaped or intensified by early experiences. Anorexia does not only start when the first symptoms appear, but much earlier.

Genetic factors

The genes seem to play a crucial role in anorexia. The disease is more common in some families. Twin studies also show a clear connection between a person's genetic makeup and the occurrence of anorexia.

In dizygotic twins, every tenth twin develops anorexia when the other twin is already ill. In the case of identical twins, it is even every second. How exactly the genes influence the risk of disease is unclear, however.

Disturbed messenger metabolism

As with many mental illnesses, the messenger metabolism in the brain is also disturbed in anorexic people. Among other things, the level of the neurotransmitter serotonin is increased in them. The messenger substance influences eating behavior and the feeling of satiety.

Animal experiments have shown that serotonin increases the feeling of satiety and thus has an appetite suppressant. An increased level could make it easier for anorexic people to go without food.

Serotonin has other effects as well: It lifts the mood and triggers feelings of happiness. This could also make it easier for people with anorexia to refrain from eating - or even encourage them to do so. Both effects also confirm people who fast for a longer period of time, for example for religious reasons.

So serotonin could help maintain anorexic behavior. The typical symptoms of the eating disorder such as fear of weight gain and the body schema disorder cannot be explained by this.

Psychological causes

Desire for control

Anorexics often state in discussions with therapists that the desire to control their own body is one of the greatest motivations for starvation. This need for control is lived out through the strict diet.

Psychologists interpret anorexia as the expression of an internal conflict that cannot be dealt with otherwise. There are several theories in science that describe possible causes of anorexia in early childhood. Traumatic experiences - for example the divorce of the parents or the death of a family member - are often mentioned emotional causes.

puberty

At the onset of puberty, girls are at greatest risk of developing anorexia. Some experts suspect that a general overstrain in this phase of life full of upheavals can trigger anorexia.

Growing up, becoming a woman - that seems threatening to some girls. They therefore reject the change from their child's body to that of an adult woman. The severe weight loss here often has the desired effect: the extreme starvation often means that the rule does not occur, and the slim figure is more like that of a child than that of a woman.

High performance standards

Anorexia is more common in middle and upper class families. Those affected are mostly remarkably intelligent, ambitious and perfectionist people. Extreme discipline and high demands on one's own body are typical.

Both also correspond to the prevailing values. In anorexic people, these ideals, imparted from kindergarten age, can fuel the disease.

Low self-esteem

Anorexics are also often not very self-confident. The apparent control over one's own body initially strengthens self-confidence - patients feel more confident and stronger.

Starvation is rewarded in this way, and this in turn increases the eating disorder. If stressful factors are added to this difficult life situation (e.g. a problematic relationship with the parents, divorce of the parents, tensions in the circle of friends, a move), this can trigger anorexia.

Sociological causes

Anorexia as leverage

Refusal to eat can also be used as an instrument of power over parents in conflict situations. The child quickly notices that parents are worried about their starving child. At the same time, the parents can hardly force them to eat.

The child thus reaches a position of power from which it can put the parents under pressure. Refusal to eat as a means of exerting pressure can be observed above all when there are many unresolved conflicts in the family. But it is only one of many possible causes of anorexia.

Western ideal of beauty

The western ideal of beauty is currently promoting unnaturally slim bodies. The pressure to be lean is heightened by very thin media role models. The weight of models is below normal. This distorted body ideal gives children and young people an unrealistic picture of how thin or fat a person normally is.

Constant teasing and negative comments about the figure can trigger anorexia against the background of this general "slimness madness". Conversely, everyone receives praise and admiration when they have lost weight.Diet is then often the "gateway drug" for anorexia.

Since women are judged more strongly by their appearance than men, they are even more exposed to the ideal of beauty. This could explain why women are so much more likely to develop anorexia than men. But even with men, the external appearance is increasingly coming to the fore. They, too, are now increasingly affected by anorexia.

Anorexia: examinations and diagnosis

If you suspect anorexia, your pediatrician or family doctor is a good first point of contact. He can first assess the extent of the risk by examining the patient and determining blood values.

A typical feature of anorexia is the lack of insight into the disease. In many cases, it is therefore not the person affected who seeks medical or psychological help, but relatives who are concerned.

Anamnesis interview

At the beginning of every medical or psychological consultation there is the anamnesis: In the conversation, the patient reports on his personal anorexia story, any physical complaints and previous illnesses. If anorexia is suspected, the doctor could ask the following questions, for example:

• Do you feel too fat?
• What's your weight?
• How much have you lost weight in the past four weeks?
• Are you trying to lose weight on purpose, for example through excessive exercise or inadequate nutrition?
• What is your goal weight?
• (in girls / women :) Has the menstrual period stopped?
• Do you have any other physical complaints such as weakness, dizziness or palpitations?

Physical examination

The physical examination follows the conversation. The doctor gets a general overview of the general physical condition. Among other things, he will listen to the heart and stomach with the stethoscope.

It also measures the body weight and height of the person concerned in order to determine the body mass index - as an objective measure of underweight. Underweight starts with a BMI of less than 17.5. The BMI of anorectic people is often well below that.

Blood tests

The doctor also receives important information about the general physical condition by determining various blood values. For example, blood tests can be used to check the function of the liver and kidneys as well as blood formation and to identify dangerous disturbances in the salt balance (electrolyte balance).

Further medical examinations

Malnutrition can damage every organ system in the body. It therefore depends on the specific complaints which further examinations the doctor will carry out.

Psychological research

Anorexia is a mental illness. The psychological symptoms are therefore decisive for the diagnosis. They are recorded in the form of various questionnaires and clinical interviews.

"Eating Disorder Inventory" (EDI)

A professional questionnaire on eating disorders such as anorexia and bulimia is the "Eating Disorder Inventory" (EDI) from Garner. The current EDI comprises 91 questions that capture the typical psychological characteristics of anorexia and bulimia patients. They can be divided into eleven categories:

• Striving for slimness - e.g. B: "I'm terrified of gaining weight."
• Bulimia - e.g. B: "I stuff myself with food."
• Dissatisfaction with the body - e.g. B: "I think my hips are too wide."
• Self-doubt: "I don't think much of myself."
• Perfectionism - e.g. For example: "Only top performances are good enough in my family."
• Distrust - e.g. B: "I find it difficult to express my feelings towards others."
• Interoceptive perception - e.g. B: "I have feelings that I can hardly name."
• Fear of growing up - e.g. B: "I wish I could go back to the security of childhood."
• Asceticism - e.g. B: "I am embarrassed about my physical needs."
• Impulse regulation and social insecurity - e.g .: "I experience significant mood swings."

Diagnostic interviews

Psychotherapists often use the Diagnostic Interview for Mental Disorders (DIPS) or the Structured Clinical Interview for DSM-IV (SKID) to make a diagnosis. They can be used to diagnose eating disorders as well as other psychiatric illnesses.

To do this, the psychotherapist asks questions that the patient answers freely. The therapist classifies the answers with a point system.

Diagnostic criteria of anorexia

Anorexia is diagnosed when the following four symptoms are present:

• Underweight (at least 15 percent below normal weight)
• self-induced weight loss
• Body schema disorder
• Disorders in the hormonal balance (endocrine disorders)

Self-assessment anorexia test

The best-known anorexia test for self-assessment is the "Eating Attitude Test" (EAT) by Garner and Garfinkel. The EAT comprises 26 statements on eating behavior and posture with regard to figure and weight. They are answered on a scale from "always" to "never".

Examples of statements in the EAT are:

• "I avoid eating even when I'm hungry."
• "I especially avoid foods high in carbohydrates."
• "Other people think I'm too thin."
• "I feel like throwing up after eating."
• "I'm obsessed with getting thinner."

Anorexia Tests on the Internet

Self-tests on the Internet also ask about typical thought patterns and behaviors in eating disorders. Such online tests for anorexia cannot replace a medical or psychological examination, but they can provide an initial indication of whether the eating behavior is disturbed.

Anorexia: treatment

Anorexia is more than an out-of-control ideal of beauty. It is a very serious and life-threatening disease that almost always requires professional treatment.

The main goals of anorexia treatment are:

• Normalization of weight
• Change in eating habits
• Restoring normal body awareness
• Therapy of individual and family problems

Anorexia is associated with both physical and emotional symptoms. For this reason, the treatment is usually carried out in cooperation with a multi-professional team. Such a team includes doctors, psychologists, dietitians and, if necessary, other specialists.

Inpatient treatment

Anorexic people can be cared for on an outpatient, inpatient or partial inpatient basis. In most cases, however, inpatient treatment in a clinic specializing in anorexia is necessary.

This is especially true for patients with a body weight of less than 75 percent of normal weight, a life-threatening physical condition or a risk of suicide due to depression. The goal is a long-term change in behavior and not just a short-term increase in weight.

Normalization of weight

The individual target weight is usually set at the beginning of treatment. For a successful course of therapy, patients should gain between 500 and 1000 grams per week.

In addition, a therapy plan is created that is tailored to individual needs. An important part of the therapy is the control of the achieved weight. According to studies, patients who leave the clinic before they reach normal weight are more at risk of relapsing again.

Severely underweight and the associated lack of electrolytes (for example of potassium or sodium) require artificial force-feeding in an emergency in order to keep the patient alive.

Learning to eat normally

Anorexics have to relearn how to handle food normally. Therefore, nutritional advice, cooking classes, grocery shopping and an individual meal plan are part of the program in many clinics.

Operant conditioning is also used to motivate patients to eat. This means that desired behavior - in this case eating - is rewarded or non-compliance is punished. A reward or punishment can, for example, be the permission or prohibition of visitors.

psychotherapy

"Focal psychodynamic therapy" appears to be particularly effective in the treatment of anorexia. This further development of psychoanalysis was specially tailored to people with anorexia. It treats the causes of anorexia and helps patients cope with everyday life.

The focus here is on dealing with emotions. Above all, the individual triggers for this disease are explored. Without treating the emotional roots of the disease, the risk of relapse is very high.

Therefore, the treatment of anorexia includes regular psychotherapeutic hours in individual and / or group sessions. In these sessions, work is also carried out to consolidate a realistic body image.

Group therapy

Group therapy is a useful help for anorexia. Patients can share their experiences with other sufferers and see that they are not alone with the problem.

Family therapy

Family therapy can be very effective, especially in young patients, because the anorexic needs family support to heal.

The family members are often overwhelmed with the disease. Good guidance and a contact person for the family help both the patient to find their way around the home and the family members to deal with the situation.

Medication

So far there is no drug that successfully supports weight gain. In many cases, however, other psychological disorders occur in addition to anorexia, for example depression or obsessive-compulsive disorder. These disorders can be treated with medication, among other things.

Lack of insight into the disease

Since people with anorexia often have no insight into the disease, many sick people are not receiving treatment.

In the event of acute mortal danger and a lack of willingness to treat, patients can be admitted to hospital against their will by a court order.

Anorexia: course and prognosis

Anorexia nervosa can develop very differently from person to person. Basically, the younger the patient, the better the chances of recovery. In addition, the prognosis depends largely on how low the weight is, how long the patient has been anorexic and what physical and mental resources he has. In addition, the support of the social environment and especially the family is extremely important for the recovery of the anorexic.

Not everyone is healed

Some of the anorexics cannot be completely cured. It is estimated that half of anorexic people will struggle with the disease for life. Even after weight normalization, the distorted attitude towards weight and figure persists in many of those affected.

Switch to bulimia

Approximately 20 percent of those affected develop another eating disorder, starting with anorexia: bulimia (eating and vomiting addiction). This is an eating disorder in which a lot of food is consumed in cravings and vomited again immediately afterwards.

Long-term physical and emotional consequences

It is not surprising that anorexia that begins in childhood or early adolescence has particularly serious consequences: Significant developmental delays, both physically and mentally, are a typical consequence of malnutrition. The onset of puberty is delayed and growth is disturbed.

The physical effects of anorexia are often severe because malnutrition damages all organs. The body does not always fully recover from this.

risk of death

Anorexia is a very dangerous mental illness. In some of the patients the disease is fatal - either because of the massive deficiency symptoms or because of suicide as a result of the accompanying depression.

Recovery is a lengthy process with progress, but often also with regression. Longer therapeutic care is necessary even after a stay in hospital. But the good news is: it's worth the effort.

Anorexia: What is "Pro Ana"?

"Pro Ana" is a movement on the Internet that does not understand anorexia nervosa as a disease, but glorifies it as a lifestyle of one's own choosing. On the corresponding websites, girls in particular exchange ideas about how they can lose weight even further in order to match their "ideal body image". Despite the threat to their lives, young people incite one another to eat as little as possible.

The "Pro Ana" movement originated in the USA and spread from there to Europe. "Ana" stands for anorexia (anorexia), "pro" clarifies the commitment to anorexia.

Anorexics who visit "Pro Ana" sites are well aware that they are diagnosed with anorexia. However, they do not want to be cured of their anorexia, but rather to become even thinner. They see the anorexic body as a desirable ideal of beauty - a life-threatening attitude.

Access to these Internet pages is often only possible with a password. Particularly strict "Pro Ana" forums allow people to go through a kind of application process before they are accepted into the online community in order to avoid unwanted guests.

The "Pro Ana" websites are very popular. It is estimated that 40 percent of all teenagers with anorexia visit Pro Ana sites.

Corresponding websites are also available for bulimia. These are known as "Pro-Mia". Bulimia, like anorexia, is an eating disorder. In contrast to anorexics, bulimics suffer from eating and vomiting attacks.

Religious imprint

Anorexia is practiced on "Pro Ana" sites similar to a religion. On such pages you will find, for example, ten commandments of anorexia: "1. If I am not thin, I am not attractive. 2. Being thin is more important than being healthy. 3. I have to do everything to look thinner", etc ..

There is also a creed that illustrates the morbid worldview of anorexics ("I believe in a world that is all black and white, in weight loss, the forgiveness of sins, the rejection of the flesh and a life full of hunger . ").

Photos of lean role models

The "Pro Ana" pages are also used to show photos of severely emaciated actors and other celebrities. Sometimes the anorexic also upload photos of their own bodies. Those suffering from anorexia share their daily "successes" and report how much they have lost weight and how little food they have eaten. Gaining weight is considered a failure.

Anonymous exchange and mutual reinforcement

Anonymous contact on the Internet enables anorexic to exchange ideas without restriction. The problem is that the anorectics feel confirmed in their behavior by other anorexics.

We-feeling

The exchange among like-minded people creates a sense of togetherness. The followers of the movement feel like extraordinary people who are strong enough to withstand the feeling of hunger and to control their bodies.

There is also strong competitive pressure among the supporters. Everyone wants to be even thinner than the others and prove how strong-willed they are.

In addition, anorexic people receive information on how they can hide the disease from their parents and lose weight even faster. Tips are also given on how to falsify weight measurements at the doctor's.

Protective measures

This persistence of the disease has serious health effects and can be fatal. Various initiatives (e.g. jugendschutz.net) have been checking "Pro Ana" sites for a number of years and have already blocked some of them. However, it is difficult to control what is offered on the Internet - also because new pages are constantly being created.

In the meantime there are also app versions of "Pro Ana" for mobile phones. The exchange via mobile phone cannot be controlled at all. Anorexic people can use it to stay in touch around the clock. The pressure not to eat therefore exists day and night.

Pro Ana Prohibit?

There has been extensive debate over whether "Pro Ana" websites should be banned. In favor of the "Pro Ana" sites being banned, there is a risk that

• People suffering from anorexia are motivated by the content to maintain or worsen the eating disorder
• the sites create a slimming contest and promote unhealthy methods to reduce weight
• anorexia is portrayed as a positive lifestyle and the discipline to starve is glorified as a religion

On the other hand, visitors to the "Pro Ana" pages have argued that they have the right to interact with others who are just as far off as themselves.

Undoubtedly, people who follow the "Pro Ana" movement are in urgent need of psychological and medical attention. However, it is not possible to prevent the exchange of members. It is also questionable whether a ban would bring the desired effect or rather give the anorexia movement an even stronger stimulus.

Additional information:

Books:

• Overcoming Anorexia Together: A Guide for Sufferers, Friends and Relatives (Janet Treasure and June Alexander, 7th edition 2014, Beltz-Verlag)
• Eating disorder.Help with anorexia, bulimia and binge eating (Anke Nolte, 2013, Stiftung Warentest)

Guidelines:

• S3 guideline "Diagnostics and treatment of eating disorders" of the German Society for Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine (as of 2018)

Self-help groups:

• Germany: Cinderella - Counseling Center for Eating Disorders of the Action Group for Eating and Anorexia e.V .: https://www.cinderella-beratung.de/
• Austria: sowhat. Competence center for people with eating disorders: http://www.sowhat.at/
• Switzerland: Working Group Eating Disorders AES: www.aes.ch

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