Anorexia Nervosa – Highest Mortality Rate of Any Mental Disorder: Why?

Contributor: Gail Hamilton, MSN, RN, CRNP, Lisa Culler, MSN, RN, CRNP and Rebecca Elenback, MSN, RN, CRNP of Penn State Hershey Medical Center Eating Disorders Program

lady struggling with anorexiaA review of nearly fifty years of research confirms that the highest mortality rate of any mental disorder is the anorexia death rate (Arcelus, Mitchel, Wales & Nelson, 2011). Anorexia Nervosa is a life-threatening disorder due to the effects of weight loss and starvation on the body and brain.

This is further complicated when purging behaviors are also being used. Purging behaviors may include self-induced vomiting, abuse of laxatives, diuretics, diet pills, appetite suppressants or other stimulants. Sometimes patients even purge by exercising excessively.

Each patient’s risk must be evaluated individually. Their risk is affected by the extent of their food restriction and the extent and combination of any purging behaviors. Other underlying medical diagnoses may also complicate and increase the risks of complications and death.

The Symptoms and Underlying Disorders

Most eating disorder experts agree that restoring body weight is vital for the effective treatment of anorexia nervosa. Without refeeding the body, it is difficult for psychotherapy to be effective due to cognitive deficits from malnutrition.

Eating disorders involve:

  • Body image distortions
  • Irrational fear of weight
  • Irrational fear of food

In addition to having an eating disorder, some patients have:

  • Underlying anxiety
  • Depression
  • Mood disorders
  • Personality disorders
  • Even self-harm issues

These comorbid conditions can further complicate treatment and the ability of the patient to make progress toward recovery. Support systems, access to care, and reduction of triggering factors involved with anorexia nervosa are also vital for a patient to make progress versus spiraling into life-threatening situations and complications.

How Common Is Death from Anorexia

Sullivan conducted a meta-analytic study, reviewing 42 published studies to estimate the mortality associated with anorexia nervosa over time. He found a mortality rate of 5.9% (or 0.56% per year) and concluded that this rate is substantially greater than that reported for female psychiatric inpatients and the general population (Sullivan,1995).

Refeeding Syndrome

ladybug-391310_640Refeeding Syndrome is a life-threatening risk with anorexia nervosa. Experiments were done during World War II on volunteers who agreed to lose a set percentage of their body weight. It was discovered that the weight loss resulted in low blood pressure and reduction in the size of the heart muscle.

Cardiovascular collapse can occur with refeeding of the body because it is difficult for the smaller heart muscle to handle the increase in blood volume seen with refeeding. This can result in heart failure. The first few weeks of refeeding the body require close monitoring of the cardiovascular system by healthcare providers.

The heart mass can revert to normal with the appropriate weight gain. Electrolyte changes can also lead to abnormalities in the contraction of the heart muscle, particularly from low phosphorus levels. (Mehler & Andersen, 1999).

Effects on the Body

Besides the risk of heart failure with refeeding syndrome, severe weight loss causes other negative effects on the heart. The heart muscle gets smaller in size, the mitral valve may prolapse, the heart rate slows and the blood pressure decreases.

Fluid can accumulate in the sac around the heart muscle, known as pericarditis. Irregular heart rhythms, known as arrhythmias, can also occur and may even cause sudden death.

The Endocrine System

Every body system is affected by starvation. The effects on the endocrine system often result in:

  • Loss of menstrual periods for females
  • Infertility
  • Dangerously low blood sugars
  • Bone loss

The bone loss, diagnosed as osteopenia or osteoporosis depending on severity, increases the risk for fractures. Metabolism slows, along with the production of energy and body heat, and growth is arrested.

The Gastrointestinal System

orange-juice-569064_640The gastrointestinal system experiences slowing of the GI muscles, delayed gastric emptying, constipation, impaired colonic transit time and possible hepatitis. There can be more complications if purging behaviors are occurring.

Purging by vomiting can cause erosion of tooth enamel and destruction of esophageal tissue with possible tears and bleeding. It can even cause a ruptured esophagus or changes to the tissue lining that increase the risk for esophageal cancer (called Barretts esophagus). Purging by laxative abuse can cause destruction to muscles in the colon.

The Pulmonary System

The pulmonary system experiences muscle wasting and decreased pulmonary capacity with starvation. Decreased production of red blood cells, white blood cells and platelets occur. The brain also shrinks in size (cerebral atrophy) with cognitive impairment, peripheral neuropathy, and possible seizures.

Kidney function is impaired by dehydration, but also by excess consumption of water. Overall body muscle wasting occurs. The skin becomes dry and the skin color changes. Loss of hair on the head may occur while lanugo hair (the fine, downy hair on a newborn) may return on the body (Mehler, 2014).

The Chronic Nature of Anorexia

Anorexia nervosa has the highest mortality rate of any mental disorder and is further complicated by its chronic nature. Patients can progress periodically through treatment but frequently relapse into periods of malnutrition, with its life-threatening and destructive complications.

Steinhausen reviewed 119 studies covering 5,590 patients suffering from anorexia nervosa that were published in English and German literature. They were analyzed for mortality, global outcome, and other psychiatric disorders. The mortality rate was significantly higher.

Among those who survived, on average less than one-half recovered, one-third improved, and 20% remained chronically ill.

Better Outcomes?

Unfortunately, Steinhausen concluded that there was no convincing evidence that the outcome of anorexia nervosa improved over the second half of the last century. However, a longer duration of follow-up and younger age at onset of illness was associated with better outcomes (Steinhausen, 2002).

The anorexia death rate is the highest of all mental illnesses as it is a very complex and complicated disorder. It requires early diagnosis and access to care with close follow-up and often long-term treatment.


  1. Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with Anorexia Nervosa and other eating disorders. Archives of General Psychiatry, 68(7), 724-731.
  2. Mehler, P (2014). Anorexia nervosa in adults and adolescents: Medical complications and their management. In T.W. Post (Ed.), UpToDate. Waltham, MA. (Accessed on December 30, 2014)
  3. Mehler, P.S., & Andersen, A.E. (1999). Eating Disorders: A Guide to Medical Care and Complications. Baltimore, MD: The Johns Hopkins University Press.
  4. Steinhausen, H.C. (2002). The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry, 159(8), 1284-1293.
  5. Sullivan, P.F. (1995). Mortality in Anorexia Nervosa. American Journal of Psychiatry, 152(7),1073.

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.

Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on February 8, 2018
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