Anorexia nervosa

For other uses, see Anorexia nervosa (disambiguation).

Anorexia Nervosa Classification and external resources
File:Anorexia billboard.jpg
An anti-anorexia nervosa billboard featuring recovering anorexic actress Isabelle Caro
ICD-10	F50.0-F50.1
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. 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% 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 (about five to ten per cent of all cases), 12 is the peak age. According to the U.S. National Institute of Mental Health (NIMH), an estimated 0.5% to 3.7% of women will suffer from this disorder at some point in their lives.

While anorexia is sometimes associated with starvation, as pictured in the grotesquely gaunt image of a young girl, (at right) 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 vary to 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 Carpentar'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 needs to be understood and addressed on many fronts.

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 insufficent 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 aorexic 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.

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 ‘not good enough’.

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 perfectionistic 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.' But it's 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.

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% 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 with personal functions." NIMH.NIH.gov 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 (eg, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% 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.

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 pyschological conditions, or the predisposition towards those conditions, such as depression or obsessive compulsive disorder can be contributing factors in and of themselves.

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. However, this review also noted that there are only a small number of randomised 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 and in particular, a method developed at the Maudsley Hospital in London is widely used and found to maintain improvement over time. 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 antidepressants 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.

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 - 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, etc., 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 avaiable 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, WA (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.

.

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. (see the video Maudsely Hospital [9]. Brain based research which is increasingly contributing to our 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. 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.

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% of patients followed at least 4 years after the onset of illness are considered recovered, i.e., being within 15% of ideal body weight, one-quarter of patients remain seriously ill, and another 5% have succumbed to the illness and died. Other studies have reported mortality rates as high as 20% in chronically ill adults with AN.

Anorexia and bulemia

Anorexia is often accompanied by bulemia; 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 bingeing 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 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.

Other eating disorders

The main types of eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder, and there are also many subtypes. Although anorexia is the illness that receives the most media attention, bulimia is in fact more common.

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.

Controversies?

Feminist writers such as Susie Orbach and Naomi Wolf have criticized the medicalization of extreme dieting and weight-loss as locating the problem within the affected women, rather than in a society that imposes concepts of unreasonable and unhealthy thinness as a measure of female beauty. ??????? seems irrelvant; from wikipedia.

References

ISBN links support NWE through referral fees

• "Anorexia Nervosa; Study challenges efficacy of SSRI treatment for adolescent anorexia nervosa"

Pain & Central Nervous System Week. Atlanta: May 16, 2005. pg. 40

• Le Grange, D."The Maudsley family-based treatment for adolescent anorexia nervosa." World Psychiatry: 2005. pg. 142-6

• Herzog, David B; Dara N Greenwood & David J Dorer et al. "Mortality in eating disorders: A descriptive study." International Journal of Eating Disorders. 2000, 28 (1): 20-26

• "DSM-IV Sourcebook: Volume 3." American Psychiatric Association. 1997.

• World Psychiatry. 2005 October; 4(3): 142–146."The Maudsley family-based treatment for adolescent anorexia nervosa"

[10]

External links

Support organizations and information

• beat: beating eating disorders UK national charity. Retrieved May 3, 2008.
• Understanding eating distress from mental health charity Mind. Retrieved May 3, 2008.
• MayoClinic eating disorders information. Retrieved May 3, 2008.
• BBC Mental Health on eating disorders. Retrieved May 3, 2008.
• Anorexia nervosa NHS Direct. Retrieved May 3, 2008.
• Anorexia Nervosa: Signs, Symptoms, Causes, Effects, and Treatments Useful information about anorexia. Retrieved May 3, 2008.
• Something Fishy Wesbsite on eating disorders Compulsive Overeating. Retrieved July 26, 2008.
• Center for Counseling and Health Resources Bellingham, WA. Retrieved July 27, 2008.
• NIMH.NIH.gov - 'Working to improve mental health through biomedical research on mind, brain, and behavior', National Institute of Mental Health (United States) Retrieved July 27, 2008.

Media stories and reports

• Anorexia goes high-tech - Time magazine on pro-ana websites. Retrieved May 3, 2008.
• Fighting Anorexia: No One to Blame - Newsweek on the increasing prevalence of anorexia in young people. Retrieved May 3, 2008.
• More 4 News report on how eating disorders are increasingly affecting men as well as women.Retrieved May 3, 2008.
• "This is the story of Karen Carpenter's Anorexia from her success in the Carpenters to her eventual death in 1983. Retrieved May 3, 2008.
• Resources on Anorexia Nervosa and other Eating Disorders including an hour long program on the subject. Retrieved May 3, 2008.

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