Anorexia nervosa is an eating disorder that is characterized by severe weight loss and altered self-image that leads sufferers to believe that they are fat even when they are, in fact, dangerously underweight.
Causes and incidence
The causes of anorexia are unclear, but the condition may be linked to a lack of self-worth that leads to excessive concern over physical appearance. Sufferers may feel that they can have some control over their lives by controlling their eating. Normal dieting may develop into starvation. Anorexia nervosa most commonly affects teenage girls and young women, but the incidence in young men is rising.
Symptoms and signs
In the early stages, sufferers may be overactive and may exercise excessively. They are obsessed with food, and often make complicated meals for others, but are reluctant to eat socially and avoid eating the meals themselves. As their weight loss continues, they become tired and weak, the skin becomes dry, lanugo hair (fine, downy hair) grows on the body, and normal hair becomes thinner. Starvation leads to amenorrhoea (the absence of menstrual periods) in many women. Some sufferers of anorexia nervosa have food binges and then make themselves vomit, or take laxative drugs or diuretic drugs, to promote weight loss. Chemical imbalances as a result of starvation, with or without vomiting, can cause potentially fatal cardiac arrhythmias
Treatment and outlook
Hospital treatment is often necessary and is usually based on a closely controlled feeding programme combined with psychotherapy or family therapy. For some people, antidepressant drugs may be helpful. Many sufferers relapse after treatment, and long-term psychotherapy is required.
Anorexia in detail - not technical
Anorexia nervosa is a psychiatric disorder characterized by an unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. The individual is obsessed with becoming increasingly thinner and limits food intake to the point where health is compromised. The disorder can be fatal. The name comes from two Latin words that mean nervous inability to eat.
Anorexia is a disorder of industrialized countries where food is abundant and the culture values a thin appearance. About 1% of Americans are anorectic and female anorectics outnumber males 10:1. In men the disorder is more often diagnosed in homosexuals than in heterosexuals. Some experts believe that number of diagnosed anorectics represents only the most severe cases, and that many more people have anorexic tendencies, but their symptoms do not rise to the level needed for a medical diagnosis.
Anorexia has been characterized as a ‘‘rich white girl’’ disorder. Most anorectics are white, and about three-quarters of them come from households at the middle income level or above. However, in the 2000s, the number of blacks and Hispanics diagnosed with anorexia has increased.
Anorexia can occur in people as young as age 7. However, the disorder most often begins during adolescence. It is most likely to start at one of two times, either age 14 or 18. Interestingly, this corresponds with the age of transitioning into and out of high school. There is a secondary peak of individuals who become anorexic in their 40s. The younger the age at which anorexic behavior starts, themore difficult it is to cure. Preteens who develop anorexia often show signs of compulsive behavior and depression in addition to anorexia.
Anorexia is often thought of as a modern problem, but the English physician Richard Morton first described it in 1689. In the twenty-first century anorexia nervosa is recognized as a psychiatric disorder in the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition (DSM-IV-TR) published by the American Psychiatric Association.
Individuals with anorexia are on an irrational, unrelenting quest to lose weight, and no matter how much they lose and how much their health is compromised, they want to lose more weight. Recognizing the development of anorexia can be difficult, especially in a society that values and glamorizes thinness.
Dieting is often the trigger that starts a person down the road to anorexia. The future anorectic may begin by skipping meals or taking only tiny portions. She (mostanorectics are female) always has an excuse for why she does not want to eat, whether it is not feeling hungry, feeling ill, having just eaten with someone else, or not liking the food served. She also begins to read food labels and knows exactly how many calories and how much fat are in everything she eats. Many anorectics practically eliminate fat and sugar from their dietsand seem to live on diet soda and lettuce.
Some future anorectics begin to exercise compulsively to burn extra calories. Eventually these practices have serious health consequences. At some point, the line between problem eating and an eating disorder is crossed.
Anorectics spend a lot of time looking in the mirror, obsessing about clothing size, and practicing negative self-talk about their bodies. Some are secretive about eating and will avoid eating in front of other people. They may develop strange eating habits such as chewing their food and then spitting it out, or they may have rigid ideas about ‘‘good’’ and ‘‘bad’’ food. Anorectics will lie about their eating habits and their weight to friends, family, and healthcare providers. Many anorectics experience depression and anxiety disorders.
There are two major subtypes of anorectics.
Restrictive anorectics control their weight by rigorously limiting the amount of calories they eat or by fasting. They may exercise excessively or abuse drugs or herbal remedies claim to increase the rate at which the body burns calories. Purge-type anorectics eat and then get rid of the calories and weight by self-induced vomiting, excessive laxative use, and abuse of diuretics or enemas.
Competitive athletes of all races have an increased risk of developing anorexia nervosa, especially in sports where weight it tied to performance. Jockeys, wrestlers, figure skaters, cross-country runners, and gymnasts (especially female gymnasts) have higher than average rates of anorexia. People such as actors, models, cheerleaders, and dancers (especially ballet dancers) who are judged mainly on their appearance are also at high risk of developing the disorder.
Causes and symptoms
Anorexia is a complex disorder that does not have a single cause but appears to result from the interaction of cultural and biological factors. Research suggests that some people have a predisposition toward anorexic and that something then triggers the behavior, which then becomes self-reinforcing. Hereditary, biological, psychological and social factors all appear to play a role.
While the precise cause of the disorder is not known, it has been linked to the following:
- Heredity. Twin studies show that if one twin has anorexia nervosa, the other has a greater likelihood of developing the disorder. Having a close relative, usually a mother or a sister, with anorexia nervosa also increases the likelihood of other (usually female) family members developing the disorder. However, when compared to many other diseases, the inherited component of anorexia nervosa appears to be fairly small.
- Biological factors. There is some evidence that anorexia nervosa is linked to abnormal neurotransmitter activity in the part of the brain that controls pleasure and appetite. Neurotransmitters are also involved in other mental disorders such as depression. Research in this area is relatively new and the findings are unclear. People with anorexia tend to feel full sooner than other people. Some researchers believe that this is related to the fact that stomach of people with anorexia tends to empty more slowly than normal; others think it may be related to the appetite control mechanism of the brain.
- Psychological factors. Certain personality types appear to be more vulnerable to developing anorexia nervosa. Anorectics tend to be perfectionists who have unrealistic expectations about how they ‘‘should’’ look and perform. They tend to have a black-or-white, right-or-wrong, all-or-nothing way of seeing situations. Many anorectics lack a strong sense of identity and instead take their identity from pleasing others. Virtually all anorectics have low-self worth. Many experience depression and anxiety disorders, although researchers do not know if this is a cause or a result of the eating disorder.
- Social factors. Anorectics are more likely to come either from overprotective families or disordered families where there is a lot of conflict and inconsistency. Either way, the anorectic feels a need to be in control of something, and that something becomes body weight. The family often has high, sometimes unrealistic and rigid, expectations. Often something stressful or upsetting triggers the start of anorexic behaviors. This may be as simple as a family member teasing about the person’s weight, nagging about eating junk food, commenting on how clothes fit, or comparing the person unfavorably to someone who is thin. Life events such as moving, starting a new school, breaking up with a boyfriend, or even entering puberty and feeling awkward about one’s changing body can trigger anorexic behavior. Over-laying the family situation is the unrelenting media message that thin is good and fat is bad; thin people are successful, glamorous, and happy, fat people are stupid, lazy, and failures.
Although anorexia nervosa is still considered a disorder that largely affects women, its incidence in the male population is rising. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals (e.g., jockey) and increasing media emphasis on external appearance in men. Moreover, homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard ‘‘attractive’’ weight for heterosexual males.
Signs and Symptoms
Anorexic behavior has physical and psychological consequences. These include:
- excessive weight loss;
- loss of muscle stunted growth and delayed sexual maturation in preteens
- gastrointestinal complications: liver damage, diarrhoea, constipation, bloating, stomach pain
- cardiovascular complications: irregular heartbeat, low pulse rate, cardiac arrest
- urinary system complications: kidney damage, kidney failure, incontinence, urinary tract infections
- skeletal system complications: loss of bone mass, increased risk of fractures, teeth eroded by stomach acid from repeat vomiting
- reproductive system complications (women): irregular menstrual periods, amenorhhoea, infertility
- reproductive system complications (men): loss of sex drive, infertility
- fatigue, irritation, headaches, depression, anxiety, impaired judgment and thinking
- fainting, seizures, low blood sugar
- chronically cold hands and feet weakened immune system, swollen glands, increased susceptibility to infections
- development of fine hair called lanugo on the shoulders, back, arms, and face, head hair loss, blotchy, dry skin
- potentially life-threatening electrolyte imbalances
- increased risk of self-mutilation (cutting)
- increased risk of suicide
Diagnosis of anorexia nervosa is made when the individual meets the criteria for the disorder outlined in theDSM IV-TR.
Anorexia is diagnosed when most of the following conditions are present:
- an overriding obsession with food and thinness that controls activities and eating patterns every hour of every day
- the individual weighs less than 85% of the average weight for his or her age and height group and willfully and intentionally refuses to maintain an appropriate body weight
- extreme fear of gaining weight or becoming fat, even when the individual is significantly underweight
- a distorted self-image that fuels a refusal to admit to being underweight, even when this is demonstrably true
- refusal to admit that being severely underweight is dangerous to health
- for women, three missed menstrual periods in a row after menstruation has been established
Diagnosis is based on several factors including a patient history, physical examination, laboratory tests, and a mental status evaluation. A patient history is less helpful in diagnosing anorexia than in diagnosing many diseases because many people with anorexia lie repeatedly about how much they eat and their use of laxatives, enemas, and medications. The patient may, however, complain about related symptoms such as fatigue,headaches, dizziness,constipation, or frequent infections.
A physical examination begins with weight and blood pressure and moves through all the signs listed above. Based on the physical exam, the physician will order laboratory tests. In general these tests will include a full blood count (FBC), urinalysis, blood chemistries (to determine electrolyte levels), and liver function tests. The physician may also order an electrocardiogram to look for heart abnormalities. Other conditions including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome can cause weight loss or vomiting after eating. People with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The physician may perform tests needed to rule out the presence of these disorders and assess the patient’s nutritional status.
The individual may be referred to a psychiatrist for a mental status evaluation. The physician will evaluate things such as whether the person is oriented in time and space, appearance, observable state of emotion (affect), attitude toward food and weight, delusional thinking, and thoughts of self-harm or suicide. This evaluation helps to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).
Treatment choices depend on the degree to which anorexic behavior has resulted in physical damage and whether the person is a danger to him or herself. Medical treatment should be supplemented with psychiatric treatment. Patients are frequently uncooperative and resist treatment, denying that their life may be endangered and insisting that the doctor only wants to ‘‘make them get fat.’’
Hospitalization is recommended for anorexics with any of the following characteristics:
- weight of 40% or more below normal; or weight loss over a three-month period of more than 30 pounds
- severely disturbed metabolism
- severe binging and purging
- signs of psychosis
- severe depression or risk of suicide
- family in crisis
Hospital impatient care is first geared toward correcting problems that present as immediate medical crises, such as severe malnutrition, severe electrolyte imbalance, irregular heart beat, pulse below 45 beats per minute, or low body temperature. Patients are hospitalized if they are a high suicide risk, have severe clinical depression, or exhibit signs of an altered mental state. They may also need to be hospitalized to interrupt weight loss, stop the cycle of vomiting, exercising and/or laxative abuse, treat substance disorders, or for additional medical evaluation.
Day treatment or partial hospitalization where the patient goes every day to an extensive treatment program provides structured mealtimes, nutrition education, intensive therapy, medical monitoring, and supervision. If day treatment fails, the patient may need to be hospitalized or enter a full-time residential treatment facility.
Anorexia nervosa is a chronic disease and relapses are common and to be expected. Outpatient treatment provides medical supervision, nutrition counseling, self-help strategies, and therapy after the patient has reached some weight goals and shows stability.
A nutrition consultant or dietitian is an essential part of the team needed to successfully treat anorexia. The first treatment concern is to get the individual medically stable by increasing calorie intake and balancing electrolytes. After that, nutritional therapy is needed support the long process of recovery and stable weight gain. This is an intensive process involving of nutrition education, meal planning, nutrition monitoring, and helping the anorectic develop a healthy relationship with food.
Medical intervention helps alleviate the immediate physical problems associated with anorexia, but by itself, it rarely changes behavior. Psychotherapy plays a major role in the helping the anorectic understand and recover from anorexia. Several different types of psychotherapy are used depending on the individual’s situation. Generally, the goal of psychotherapy is help the individual develop a healthy attitude toward their body and food. This may involve addressing at the root causes of anorexic behavior as well as addressing the behavior itself.
Some types of psychotherapy that have been successful in treating anorectics are listed below.
- Cognitive behavior therapy (CBT) is designed to change the individual’s thoughts and feelings about his or her body and behaviors toward food, but it does not address why those thoughts or feelings exist. This therapy is relatively short-term
- Psychodynamic therapy, also called psychoanalytic therapy, attempts to help the individual gain insight into the cause of the emotions that trigger their anorexic behavior. This therapy tends to be longer term that CBT.
- Interpersonal therapy is short-term therapy that helps the individual identify issues and problems in relationships. The individual may be asked to look back at his or her family history to try to recognize problem areas and work toward resolving them.
- Family and couples therapy is helpful in dealing with conflict or disorder that may be a factor in perpetuating anorexic behavior. Family therapy is especially useful in helping parents who are anorectics avoid passing on their attitudes and behaviors on to their children.
Anorectics are treated with a variety of medications to address physical problems brought about by their eating disorder and to treat additional psychiatric problems such as depression, anxiety, and suicidal thoughts. The medications used will vary depending on the individual, however, depression is common among anorectics and is treated often treated with antidepressant drugs.
Alternative treatments should serve as complementary to a conventional treatment program. Alternative therapies for anorexia nervosa include diet and nutrition counseling, herbal therapy,hydrotherapy, aromatherapy, Ayurvedic medicine, and mind/body medicine.
The following herbs may help reduce anxiety and depression which are often associated with this disorder:
- chamomile (Matricaria recutita)
- lemon balm (Melissa officinalis)
- linden (Tilia spp.) flowers
Essential oils of herbs such as bergamot, basil, chamomile, sage, and lavender may help stimulate appetite, relax the body, and fight depression. They can be diffused into the air, inhaled, massaged, or put in bath water. Relaxation techniques such asyoga, meditation, and t’ai chi can relax the body and release stress, anxiety, and depression. Hypnotherapy may help resolve unconscious issues that contribute to anorexic behavior. Other alternative treatments that may be helpful include hydrotherapy, magnetic field therapy, acupuncture, biofeedback, Ayurvedic medicine, and traditional Chinese medicine.
Anorexia nervosa is difficult to treat successfully. Medical stabilization, nutrition therapy, continued medical monitoring, and substantial psychiatric treatment give a person with anorexia the best chance of recovery. Estimates suggest that between 20% and 30% of people in treatment drop out too soon and have major relapses. Even those who stay in treatment relapse occasionally. Treating anorexia is often a long, slow, frustrating process that can cost many thousands of dollars. The earlier in life that the disorder starts and the longer the disorder continues untreated, the more difficult it is bring about recovery. Many individuals with anorexia are willfully uncooperative and do not want to recover. About half the people treated for anorexia nervosa recover completely and are able (sometimes with difficulty) to maintain a normal weight. Of the remaining 50% between 6% and 20% die. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide. About 20% remain dangerously underweight, and the rest remain thin. Long-term health complications are common.
Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families. Some ways to prevent anorexia nervosa from developing are as follows:
- If you are a parent, do not obsess about your own weight and appearance in front of your children.
- Do not tease your children about their body shapes or compare them to others.
- Make it clear that you love and accept your children as they are.
- Try to eat meals together as a family whenever possible.
- Remind children that the models they see on television and in fashion magazines have extreme, not normal or healthy bodies.
- Do not put your child on a diet unless advised to by your pediatrician.
- Block your child from visiting pro-anorexia Web sites. These are sites where people with anorexia give advice on extreme weight loss techniques and support each other’s distorted body image.
- If your child is a competitive athlete, get to know the coach and the coach’s attitude toward weight.
- If you think your child has an eating disorder, do not wait to intervene and get professional help. The sooner the disorder is treated, the easier it is to cure.
Relapses happen to many people with anorexia. People who are recovering from anorexia can help prevent themselves from relapsing by:
- never dieting; instead plan healthy meals
- staying in treatment
- monitoring negative self-talk
- practicing positive self-talk
- spending time doing something enjoyable every day
- staying busy, but not overly busy
- getting at least seven hours of sleep each night
- spending time each day with people you care about and who care about you
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American Psychological Association, 750 First Street, NE, Washington, DC, 20002-4242 (202) 336-5500; TDD/ TTY: (202 )336-6123 (800) 374-2721.
National Association of Anorexia Nervosa and Related EatingDisorders (ANAD), P.O. Box 7, Highland Park, IL, 60035 (847) 831-3438 (847) 433-3996.
National Eating Disorders Association, 603 Stewart Street, Suite 803, Seattle, WA, 98101 (206) 382-3587 Help and Referral Line: (800) 931-2237. (206) 829-8501.