Anorexia nervosa

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Anorexia Nervosa
Classification and external resources
ICD-10 F500-F501
ICD-9 307.1
OMIM 606788
DiseasesDB 749
eMedicine emerg/34  med/144

Anorexia nervosa is a complex condition, involving psychological, neurobiological, and sociological components.[1] It is an eating disorder characterized by an obsessive fear of gaining weight due to a distorted self image that results in a dangerously low body weight. Individuals with anorexia nervosa may use voluntary starvation, excessive exercise, or other measures such as diet pills or diuretic drugs to combat their fear. While primarily affecting adolescent females, approximately 10 percent of people with the diagnosis are male.

Anorexia is estimated to affect between one and five teenage women in every 100,000, and the age at which most cases develop is from 16 to 17. For boys who develop the problem, 12 is the peak age. According to the U.S. National Institute of Mental Health (NIMH), an estimated 0.5 percent to 3.7 percent of women will suffer from this disorder at some point in their lives.[2]

While anorexia is sometimes associated with starvation and grotesquely gaunt images of young girls, it can also be a hidden problem and go undiagnosed for years as the person engages in negative eating patterns and hovers on the borderline of an abnormal weight.

Many experts consider people for whom thinness is especially desirable, or a professional requirement (such as athletes, models, ballet dancers, actors and gymnasts) to be at risk for eating disorders such as anorexia nervosa. While treatment options include medication, counseling, and—in extreme cases, hospitalization—cultural and media images that promote "thinness as glamorous" or other distorted views of body image and beauty must be addressed by society at large.

The condition of anorexia first came to light in 1983, when it became the focus of media attention after the tragic death of Karen Carpenter, of the singing duo, The Carpenters. The popular 1970s singer died of cardiac arrest related to her low body weight and the constant demands of deprivation associated with anorexia nervosa. While the condition of aneroxia nervosa existed in the general population prior to Carpenter's untimely death it was rarely discussed and not well understood. Sometimes referred to as "the rich girl's disease," the battle against this destructive and debilitating disorder still requires education on many fronts.

Contents

Definition

The term anorexia is of Greek origin: A (α, prefix of negation), n (ν, link between two vowels), and orexis (ορεξις, appetite), thus meaning a lack of desire to eat or lack of appetite. Anorexia nervosa is frequently shortened to "anorexia" in both the popular media and television reports. However, the word "anorexia" by itself is insufficient to describe the disorder which is more complex than simply the term for "reduced appetite." In fact, a gross oversimplification of the disorder would be to describe an anorexic as someone who is "unwilling to eat" just as it would be an oversimplification to say that someone suffering from insomnia is "unwilling to sleep" when "unable"—due to the stressors related to the disorder—would be more accurate.

History

Anorexia nervosa was first given its name in 1868, by William Withey Gull, a British physician at Guy's Hospital, London.[3] The disease was first documented in 1873, by Charles Lasgue, when he wrote L'anorexie Hysterique. His book chronicled the stages of this disease in young French girls. He said that the disorder typically began between the ages of 15 to 20 and had three distinct stages.[4]

In the late nineteenth century, the public attention drawn to "fasting girls" provoked conflict between religion and science. Such cases as Sarah Jacob (the "Welsh Fasting Girl") and Mollie Fancher (the "Brooklyn Enigma") stimulated controversy as experts weighed the claims of complete abstinence from food. Believers referenced the duality of mind and body, while skeptics insisted on the laws of science and material facts of life. Critics accused the fasting girls of hysteria, superstition, and deceit.

During the Victorian Era, the disorder was thought to be a form of hysteria that affected mainly women of the middle and upper classes. Obesity during this era was thought to be a characteristic of poverty. In general however, the ideal woman’s body type during the Victorian era was one that was curvy and full- figured. Many women attempted to achieve this body type through the use of corsets. The role of restrictive corsets during the Victorian era exemplifies how women, as early as the late eighteenth century, began taking extreme measures to achieve the believed ideal body type.

Sometime midway in the twentieth century, the mass media became the chief purveyors of the idea that slimness is the ideal image of feminine beauty. This constant emphasis has caused many women to incessantly diet in order to keep up with the demands of modern fashion. In a 1984 survey carried out by Glamor magazine, of thirty-three thousand women between the ages of eighteen and thirty-five, 75 percent believed they were fat, although only 25 percent were actually overweight. Indications of being thin were important to women of the upper class, and this class specific cultural model became pervasive throughout the media.

In 1983, when Karen Carpenter died, anorexia nervosa was not commonly talked about by the media. But following Carpenter's death, the history of anorexia and the disease in current culture came into public discourse.

Causes and symptoms

Anorexia Nervosa, like other eating disorders, cannot be attributed to a single cause. The causes of the disorder are much more likely to be attributable to a combination of factors - biological, psychological, or social in nature. These include the many pressures which can lead a young person feeling unable to cope with the stress of approaching adulthood. Other issues that can possibly impact a person's anorexic response to life stressors are family relationships, the death of someone significant, problems at work or school, poor or lacking self concept, and even sexual or emotional abuse. Anorexics suffering from this disorder may equate feeling "too fat" with not being "good enough."[5]

Genetics may contribute considerably to a person's predisposition towards anorexia nervosa, as can be the case with other psychiatric or medical conditions; therefore family history should be taken into account when investigating a diagnosis.

An anorexic person feeling helpless or anxious gains a sense of "mastery" by obsessively and rigidly monitoring their diet. Their perfectionist control of their outer needs masks their internal feelings of inadequacy and anxiety, therefore, not eating and losing weight become that person's only way of feeling "safe" and "in control."[6] But it is important to remember that this kind of intense starvation is not the only symptom of an eating disorder. A person with an eating disorder may maintain a normal body weight and so their condition may go unnoticed for a long period of time. This, however, is more often the case with bulimia which is easier to hide as a person may appear to be eating normally, but in private purge what they have taken in through meals.[7]

As with any illness, whether it be psychiatric in origin or not, finding the proper diagnosis is an important first step in securing the most appropriate and effective treatment.

Other effects may include but are not limited to the following:

  • Extreme weight loss
  • Body mass index less than 17.5 in adults, or 85 percent of expected weight in children
  • Stunted growth
  • Endocrine disorder, leading to cessation of periods in girls (amenorrhoea)
  • Decreased libido; impotence in males
  • Starvation symptoms, such as reduced metabolism, slow heart rate (bradycardia), hypotension, hypothermia and anemia
  • Abnormalities of mineral and electrolyte levels in the body
  • Thinning of the hair
  • Growth of lanugo hair over the body
  • Constantly feeling cold
  • Zinc deficiency
  • Reduction in white blood cell count
  • Reduced immune system function
  • Pallid complexion and sunken eyes
  • Headaches
  • Brittle fingernails
  • Bruising easily
  • Fragile appearance; frail body image

Diagnosis

According to the World Health Organization a mental disorder is defined as the "existence of a clinically recognizable set of symptoms or behaviors associated with distress and with interference of personal functions."[8] In other words, a mental disorder is diagnosed when a person has a constellation of symptoms that interfere with that person's ability to be fully functioning whether that is in their everyday life at school, work or at home.

The most commonly used criteria for diagnosing anorexia nervosa are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD).

Although biological tests can aid in recognizing anorexia nervosa, the diagnosis is truly based on observation of the behavior, reported beliefs and experiences, and physical characteristics of the patient.

To be diagnosed as having anorexia nervosa, according to the DSM-IV-TR, a person must display:

  1. Refusal to maintain body weight at or above a minimally normal weight for age and height (for example, weight loss leading to maintenance of body weight less than 85 percent of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85 percent of that expected).
  2. Intense fear of gaining weight or becoming obese.
  3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
  4. The absence of at least three consecutive menstrual cycles (amenorrhea), in women who have had their first menstrual period but have not yet gone through menopause (postmenarcheal, premenopausal females).
  5. Or other eating related disorders.[9]

Furthermore, the DSM-IV-TR specifies two subtypes:

  • Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (that is, self-induced vomiting, over-exercise or the misuse of laxatives, diuretics, or enemas)
  • Binge-Eating Type or Purging Type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating OR purging behavior (that is, self-induced vomiting, over-exercise or the misuse of laxatives, diuretics, or enemas).

While anorexia nervosa can be diagnosed using the above criterion, it should also be taken under consideration that other psychological conditions, or the predisposition towards those conditions, such as depression or obsessive compulsive disorder can be contributing factors in and of themselves.

Limitations with diagnoses

Additionally, it is important to note that an individual may still suffer from a health- or life-threatening eating disorder (for example, sub-clinical anorexia nervosa or EDNOS) even if one diagnostic sign or symptom is still present. For example, a substantial number of patients diagnosed with EDNOS (Eating Disorder Not Otherwise Specified) meet all criteria for diagnosis of anorexia nervosa, but lack the three consecutive missed menstrual cycles needed for a diagnosis of anorexia.

Treatment

The first line of treatment for anorexia is usually focused on immediate weight gain, especially with those who have particularly serious conditions that require hospitalization. In extreme cases, this may be done as an involuntary hospital treatment under mental health laws, where such legislation exists. In the majority of cases, however, people with anorexia nervosa are treated as outpatients, with input from physicians, psychiatrists, clinical psychologists, nutritionists, and other mental health professionals.

A recent clinical review has suggested that psychotherapy is an effective form of treatment and can lead to restoration of weight, return of menses among female patients, and improved psychological and social functioning when compared to simple support or education programs.[10] However, this review also noted that there are only a small number of randomized controlled trials on which to base this recommendation, and no specific type of psychotherapy seems to show any overall advantage when compared to other types.

Family therapy has also been found to be an effective treatment for adolescents with AN[11] and in particular, a method developed at the Maudsley Hospital in London is widely used and found to maintain improvement over time.[12] The family based treatment which is collaborative in nature offers support to parents as well as patients.

Psychiatrists commonly prescribe medications such as serotonin-reuptake inhibitors (SSRI) or other antidepressant medication with the intent of trying to treat the associated anxiety and depression. Efficacy of their use in initial treatment of anorexia nervosa is under debate.

One study showed that supplementation with 14mg/day of zinc as routine treatment for anorexia nervosa doubled weight gains in subjects studied. Researchers hypothesize that zinc consumption increases the effectiveness of neurotransmission in various parts of the brain, including the amygdala, which ultimately increases patient appetite.[13]

There are various non-profit and community groups that offer support and advice to people who suffer from AN or who care for someone who does. Several are listed in the links below and may provide useful information for those wanting more information or help with treatment and medical care.

It is extremely important to address underlying issues of anxiety, depression, and poor self image through follow-up care as these feelings can re-occur along with the much needed (although feared) weight gain.

Prevention and early detection

Being aware of the symptoms associated with any psychiatric disorder, such as anorexia nervosa, can be particularly challenging when they are hidden. Noticing the tell-tale signs of weight loss, and so on, should not be accompanied by threats or the forcing of food or eating. More often than not, this approach can result in the person reacting to perceived pressure by either withdrawing or rebelling. The best prevention is to support the person's underlying need for a better self image and to address these issues with a wholistic approach. Since a psychiatric condition impacting one person in a family affects every member, family counseling, as well as individual counseling, might be the most comprehensive strategy in preventing the disease from intensifying. While a psychiatrist can explore the best medical treatment available, a counselor can address behavioral issues through "talk therapy" and offer support in terms of successful stress management techniques.

The following advice from the website of the Center for Health Resources in Bellingham, Washington (which offers help for a variety of eating disorders and addictions), states:

Anybody that is suffering from an eating disorder needs to have unconditional love, acceptance, and forgiveness. They also need to learn how to forgive themselves, and forgive others who may have abused or harmed them. The Center does not believe force will change those suffering from eating disorders. Force does not work. It can drive the eating disorder deeper and deeper. Instead of force, at The Center, they provide an atmosphere of acceptance where change can take place. They look beyond the eating disorder and reach into the person's heart and see them as a person who needs love and acceptance.[14]

Signs to look for in a loved one that might be displaying symptoms of anorexia nervosa would be: A pre-occupation or obsessive thoughts about food and weight; mood swings and an intense fear about becoming overweight. There is cause to be concerned when the loved one withdraws from previous friendships and other peer relationships or displays signs of excessive exercise, fainting, self-harm, or is aggressive when forced to eat "forbidden" foods.

Parents often blame themselves for being unable to prevent or stop the disorder from taking over a child's life. Most scientists would concur that parents are not to blame and that eating disorders are biologically based. Brain based research which is increasingly contributing to the understanding of child development holds the key for understanding disorders of this nature.

Prognosis

Some people make a full recovery from anorexia, and others can improve their condition. However, anorexia can sometimes develop into a chronic condition. Occasionally, anorexia can be fatal.[15] The suicide rate of people with anorexia is higher than that of the general population and is the major cause of death for those with the condition.[16]

If weight loss is not reversed, major medical complications, such as bradycardia, peripheral edema, and osteoporosis, may develop. Numerous other complications can also result from AN: interference with physical development, growth, and fertility, generalized and occasional regional atrophy of the brain, poor social functioning, low self-esteem, and high rates of comorbid substance abuse, mood disorders, anxiety disorders, and personality disorders.

Outcomes for AN are generally not optimistic. Only 44 percent of patients followed at least four years after the onset of illness are considered recovered, that is, being within 15 percent of ideal body weight, one-quarter of patients remain seriously ill, and another 5 percent have succumbed to the illness and died. Other studies have reported mortality rates as high as 20 percent in chronically ill adults with AN.[17]

Anorexia and bulemia

Anorexia is often accompanied by Bulemia nervosa; that is a cycle of binge eating and purging. Bulimia is estimated to affect between one and two per cent of women aged 15 to 40. Like anorexia, bulimia develops from an obsessive desire to be thin. However, instead of not eating, the person alternates between frantic binging and drastic purging (by self-induced vomiting and the abuse of laxatives and diuretics) or periods of excessive fasting and exercise.

The distinction between the three diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make in practice and there is considerable overlap between patients diagnosed with these conditions. Furthermore, seemingly minor changes in a patient's overall behavior or attitude (such as reported feeling of "control" over any binging behavior) can change a diagnosis from "anorexia: Binge-eating type" to bulimia nervosa. It is not unusual for a person with an eating disorder to "move through" various diagnoses as his or her behavior and beliefs change over time.

Of the three three main types of eating disorders anorexia is the illness that receives the most media attention, but bulimia is in fact more common.[18]

Compulsive eaters differ from people with bulimia in that, after binge eating, they don't try to get rid of what they've eaten. Many of them feel powerless to control their desire to keep "comfort eating." Compulsive eating can go hand-in-hand with anorexia as a recovering anorexic may go to the other extreme in their eating habits.[19]

Controversies

Feminist writer and psychologist Susie Orbach (Fat is a Feminist Issue) and Naomi Wolf (The Beauty Myth) have criticized societal cultural expectations and false representations of beauty as being a large contributing factor to the problem of eating disorders. As frustrating as it is for family and friends to stand by helplessly in their efforts to combat a disorder out of their control, it is still all important not to assign blame to the person with anorexia who is already grappling with a fragile psyche and a reduced sense of self.

The Internet has enabled anorexics and bulimics to contact and communicate with each other outside of a treatment environment, with much lower risks of rejection by mainstream society. A variety of websites exist, some run by sufferers, some by former sufferers, and some by professionals. The majority of such sites support a medical view of anorexia as a disorder to be cured, although some people affected by anorexia have formed online pro-ana communities that reject the medical view and argue that anorexia is a "lifestyle choice," using the internet for mutual support, and to swap weight-loss tips. Such websites were the subject of significant media interest, largely focusing on concerns that these communities could encourage young women to develop or maintain eating disorders, and many were taken offline as a result.

Notes

  1. B. Lask and R. Bryant-Waugh (eds.), Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence (Hove: Psychology Press, 2000, ISBN 0-86377-804-6).
  2. MedicineNet, Anorexia Nervosa. Retrieved July 31, 2008.
  3. MedIndia, Anorexia Nervosa—Overview & Early History. Retrieved August 2, 2008.
  4. Christianet, History of Anorexia. Retrieved August 2, 2008.
  5. B-eat.co.uk, Understanding eating disorders and how you can help. Retrieved July 31, 2008.
  6. Mind.org.uk, Understanding eating distress. Retrieved July 31, 2008.
  7. BBC, Health. Retrieved July 31, 2008.
  8. National Institute of Mental Health, Homepage. Retrieved August 1, 2008.
  9. DSM-IV Sourcebook, Volume 3 (American Psychiatric Association, 1997).
  10. P. Hay, J. Bacaltchuk, A. Claudino, D. Ben-Tovim, P.Y. Yong, Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa, Cochrane Database Syst Rev 4 (2003). PMID 14583998.
  11. J. Lock, D. Le Grange, Family-based treatment of eating disorders, Int J Eat Disord 37 (2004): 64-7. PMID 15852323.
  12. D. Le Grange, The Maudsley family-based treatment for adolescent anorexia nervosa, World Psychiatry 4 (3): 142-6. PMID 16633532.
  13. C.L. Birmingham and S. Gritzner, How does zinc supplementation benefit anorexia nervosa? Eating and Weight Disorders 11 (4): e109-111. PMID 17272939.
  14. A Place of Hope, The Center for Counseling and Health Resources, Inc. Retrieved August 2, 2008.
  15. NHS Direct, Anorexia nervosa. Retrieved August 2, 2008.
  16. Pompili, Mancinelli, Girardi, Ruberto, and Tatarelli, Suicide in anorexia nervosa: A meta-analysis, International Journal of Eating Disorders 1(36): 99-103.
  17. NIH, The Maudsley family-based treatment for adolescent anorexia nervosa. Retrieved August 2, 2008.
  18. BBC, Health. Retrieved August 2, 2008.
  19. BBC, Health. Retrieved August 2, 2008.

References


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All links retrieved October 15, 2012.

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