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Anorexia nervosa

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Anorexia nervosa
SpecialtyPsychiatry, clinical psychology Edit this on Wikidata

Anorexia nervosa is an eating disorder characterized by voluntary starvation and exercise stress. Anorexia nervosa is a complex disease, involving psychological, sociological and physiological components. A person who is suffering from anorexia is referred to as 'anorexic' or (less commonly) 'anorectic'. "Anorectic" is the noun form, where "anorexic" is the adjectival form. These two are often used incorrectly when applied. Although technically incorrect, the term is frequently shortened to anorexia, which simply refers to the medical symptom of lost appetite. In this article, anorexia will be used synonymously with anorexia nervosa.

Anorectic can also refer to appetite-suppressing drugs.

Characteristics

The causes of anorexia are a matter of debate in medical circles and society in general. General perspectives fit between the poles of it being physiological or psychological (with the potential for sociological and cultural influences being a cause to various degrees) in origin. Some now take the opinion that it is a mix of both, in that it is a psychological condition which is often (though not inherently) borne of certain conducive neurophysiologic conditions.

Physiological

The primary physiological characteristics of anorexia nervosa are:

In addition to intentional starvation, subjects will also take part in a high level of physical activity. Anorexia nervosa also has a negative impact on the immune system and the central nervous system (CNS).

It is also thought to be linked to serotonin and dopamine abnormalities.

Many individuals develop obsessive-compulsive symptoms as part of their disease. Some have an eating-disordered parent, presumably connected with shared genetic characteristics.

Additionaly, some 1/3 of anorexic people meet diagnostic criteria for an autism spectrum disorder, a sub-group that is especially difficult to treat successfully [1]. Thus, anorexia may be the result of undetected autism in women [2].

Anorexic subjects will often go through a cycle of recovery and relapse, unless weight is restored long-term.

Neurochemistry abnormalities

There is increasing speculation that the onset of anorexia has a genetic component, with a certain gene linked to abnormalities with the neurotransmitter chemical serotonin being shown to be more common amongst sufferers than the general population. Such genetic characteristics might potentially equate to an easier path towards overly high serotonin levels, thus instilling heightened levels of anxiety and the like. Biologically, when a person is in a state of starvation, their levels of serotonin decrease, and thence increase again upon the consumption of food because of the tryptophan amino acids contained therein (tryptophan is used by the body to synthesise serotonin). This raises the spectre that the anorexic is conditioned into avoiding food to reduce his or her anxiety, and that there may be yet another layer of complexity with respects to the cause/effect relationship between physiological factors and the mental beliefs of the anorexic.

Blood chemistry abnormalities: dietary minerals and heavy metals

Victims of mercury, lead, beryllium and arsenic poisoning have been known to develop anorexia as a symptom thereof. Some psychological traits associated with anorexia are consistent with deficiencies in important vitamins and minerals, such as magnesium and the B vitamins. Zinc deficiency is common among anorexics, thereby resulting in heightened levels of copper which is associated with depression and nervousness. That these deficiencies (or untoward exposure to heavy metals) can produce powerful psychological effects, such as depression, anxiety, and loss of appetite, is not widely known. Conversely, overexposure is also harmful.

Animal model

There exists an animal model of anorexia nervosa that closely mimics the physiological effects of the disease. In the animal model, subjects are intentionally subject to starvation and given unlimited access to exercise. Under these conditions, without intervention, subjects will eventually run and starve themselves to death. Compared to cases of food restriction without exercise access, the subject will not starve themselves to death.

In the animal model of anorexia nervosa, it has been shown that repeated cycling of recover and relapse will lead to physiological adjustments from the subject. Subjects under these conditions will eventually become "resistant" to the animal model, and will not starve themselves to death. Subjects under these conditions show a metabolic adjustment.

Physiological effects in the animal model include:

  • Negative impact on the immune system
  • Negative impact on the Central Nervous System
  • Serotonin deficiency

Dangers

Anorexia has the highest death rate of any psychiatric illness. Starvation can cause major organs to shut down. A heart attack is one of the most common causes of death in those suffering with an eating disorder. People can die from eating disorders at any body weight.

Osteoporosis is another danger of anorexia. Low calcium intake is only part of the problem. Even in those who take in adequate calcium through food or supplements, amenorrhea prevents the body from absorbing it fully.

Since depression accompanies anorexia, suicide is also a risk factor. Approximately 25% of all anorextics attempt suicide, and about 50% of anorexic deaths result from suicide.

Psychological, Sociological, and Cultural

Psychological

Anorexia nervosa alters an individual's body image to the point where it is perceived as being fat and bilious irrespective of their actual size. This distorted body image is a source of considerable anxiety, and losing weight is considered to be the solution. However, when a weight-loss goal is attained, the anorexic still feels overweight and in need of further weight loss.

The attainment of a lower weight is typically viewed as a victory, and the gaining of weight as a defeat. "Control" is a factor strongly associated with anorexia nervosa, and an anorexic typically feels highly out of control in his or her life. However, the nature of the condition with respect to such psychological factors is highly complicated.

It is often the case that other psychological difficulties and mental illnesses exist alongside anorexia nervosa in the sufferer. Mild to severe manifestations of depression are common, partly because an inadequate food energy-intake is a well-known trigger for depression in susceptible individuals. Other afflictions may include self-harm and obsessive-compulsive disordered thinking (aside from such disordered thinking connected to their eating disorder). However, not all anorexics have any such problems besides their eating disorder.

Many anorexics reach a low level of body weight at which hospitalisation and forced-feeding are required on a long-term or recurring basis in an attempt to keep them from literally starving themselves to death. Prolonged starvation will result in death as the body's systems shut down, this in itself being the major danger factor of anorexia aside from intense mental suffering and the risk of suicide.

Some anorexics may incorporate bulimic behaviours into their illness: binge-eating and purging themselves of food on a regular or infrequent basis at certain times during the course of their illness. Alternatively, some individuals might switch from having anorexia nervosa to having bulimia. While bulimia poses less of a mortal danger to life and limb, many who have suffered both say that bulimia involves more mental suffering.

Anorexia alters ones body image so that one does not see the truth about oneself even when one looks in the mirror — to the anorexic mindset, there is no such thing as being too thin. Anorexics acknowledge their condition to different degrees — at one extreme, they do not see their "disease" as dangerous and resent being labelled as psychologically ill; at the other, they understand and accept that they have a problem, yet the anorexia still takes control over their thinking to fluctuating degrees. In ways not too dissimilar from people who have had cult programming or post-traumatic stress disorder, an anorexic may be "triggered" into manic disordered thinking by being exposed to certain words or conditions.

Some people eat unusually small amounts of food for reasons other than their own perceived obesity. Examples include those who fast for religious reasons, execute a hunger strike as a political statement, or are attempting to lengthen their lifespan through caloric restriction. Such individuals are not ordinarily considered anorexic, although some modern critics of religious asceticism have likened habitual fasting to anorexia nervosa.

Sociological and Cultural

Anorexia can be traced back to or connected with 19th century American society. Joan Jacobs Brumberg, in her article "The Appetite as Voice", stresses the importance of the history of anorexia nervosa. "A history of anorexia nervosa must consider the ways in which different societies create their own symptom repertoires and how the changing cultural context gives meaning to a symptom such as non-eating" (Brumberg, p.159). During the Victorian era, medical examiners were more interested in physical characterics, or what the patient's body had to say, rather than his/her description of their illness. Young women were also viewed as a non-reliable source for information. Related to the section below on contemporary culture, doctors of the 19th century viewed the connection between culture and the disease very differently. "In effect, nineteenth-century medicine did not relate anorexia nervosa to the cultural milieu that surrounded the Victorian girl. The ideas of Victorian women and girls about appetite, food, and eating, as well as the cultural categories of fat and thin, were not mentioned as contributing to the disease. Only in the twentieth century has medicine come to understand that society plays a role in shaping the form of psychological disorders and that behavior and physical symptoms are related to cultural systems" (Brumberg, p.160).

The mass media and advertorial marketing, such as beauty advertising, are also frequently viewed as being implicated in triggering eating disorders in teenage girls, although it has recently come to light that there appear to be girls exhibiting anorexic behaviours in remote parts of Africa that have not been exposed to modern forms of advertising. These girls link their self-starvation to religious causes.

Although anorexia is usually associated with western cultures, the exposure to western media has caused the disease to appear in some third-world nations.

In recent years, 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. If an anorexic is already socially withdrawn, such a network of friends can be very helpful in bringing him or her back. On the other hand, the Internet is also a powerful tool with which people can isolate themselves. A variety of websites exist, some run by sufferers, some former sufferers, and some by professionals; attitudes on these sites range through a no-holds-barred, tough-love "put it in your mouth" approach through simple acceptance and even to promotion of anorexia as an "alternate lifestyle" (see pro-ana).

Clinical definition

The four DSM IV criteria

The following is considered the "textbook" definition of anorexia nervosa to assist doctors in making a clinical diagnosis. It is in no way representative of what a sufferer feels or experiences in living with the illness. It is important to note that an individual can still suffer from anorexia even if one of the below signs is not present. In other words, it is dangerous to read the diagnostic criteria and think either oneself or others must not be anorexic because one or more of the symptoms listed are not present.

  1. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., 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 fat, even though underweight.
  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. In postmenarcheal females (women who have not yet gone through menopause), amenorrhea (the absence of at least three consecutive menstrual cycles).

The two DSM IV Subtypes

  • Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting 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 (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Risk factors

While anorexia may occur in individuals across the demographic divides, it definitely appears to be far more prone to developing among those in certain groups, such as:

  • gender: 95% of anorexia nervosa sufferers are females. However, males are at a greater risk of not recovering from the disease due to a reluctance to report symptoms.
  • age: It is most common in those of age 10 through 25. Anorexia nervosa is typically stereotyped as being a disease of teenage females. However, in real-life, almost any individual can be a sufferer, as even children as young as three have been known to develop the disease. The most common times of onset are at puberty, and during times of transition such as moving from school to university. Though many do not realize it, younger children can also exhibit symptoms of anorexia nervosa. Children as young as five years may begin to diet, perhaps mimicking behaviour they see in their parents. (For example, if a mother is obsessed with her weight, her daughter may begin to weigh herself.) These young anorexics have a fear of becoming "fat" and refuse to eat, as in classic anorexia nervosa.
  • physical activities: athletes; especially swimmers, dancers, gymnasts, and wrestlers, and people who are active in dancing, or modeling. Maintaining excessive physical activity.
  • academic activities: the highly intelligent and/or high-achievers [3], and students who are under heavy workloads
  • race: people of European racial descent
  • culture: The disease is believed to be far more common in some societies than others, especially those of Europe, the Americas, Australasia and Japan. Also, those positioned in the higher echelons of the socioeconomic scale, and perfectionists.
  • history: those who have suffered traumatic events in their lifetime such as child abuse and sexual abuse ¹

Indicators

Anorexic people may:

Physical

  • be too thin and/or appear to have lost weight;
  • have dry skin and thinning hair;
  • suffer from poor health and sunken eyes;
  • have grown lanugo, a thin hair that grows all over their body as a natural physiological reaction to severe starvation that serves to keep the body warm in the absence of fat;
  • have fainting spells or otherwise pass out (an effect of starvation);
  • have amenorrhea, the absence of menstruation. Currently, the DSM-IV lists amenorrhea as a required characteristic of diagnosis, as it nearly always accompanies anorexia nervosa in females. However, while many emaciated women will never menstruate (unless they use a form of hormonal-replacement therapy), some women cease to have their menses before appreciable weight has been lost. Conversely, a small percentage of women reach weights that are quite low and still manage to menstruate regularly. Further, the eating disorders work group of the DSM is attempting to have the amenorrhea requirement removed as it makes diagnosis in males problematic. Researchers have often pointed to lack of sexual potency in males as the equivalent of female amenorrhea, but there continues to be a lack of consensus regarding this criterion.

Behavioral

  • be secretive about their eating and try to not eat while being around others;
  • eat in a ritualistic manner (this can encompass taking abnormally small bites, cutting food up into abnormally small pieces, being sullen during mealtimes, staring at their food whilst eating, holding cutlery in odd ways or at strange angles at times, or eating slowly, especially when putting food into the mouth);
  • look longingly at or pay abnormal attention towards food but not eat it;
  • cook wonderful meals for others but avoid eating the food they've made themselves;
  • say they're too fat when they are not;
  • talk about food a lot;
  • plan their meals up to days in advance;
  • possess an extensive knowledge about the food energy contents of the different types of food, and the energy-burning effects of each form of exercise. Although anorexics are less likely to choose fattening foods to eat, this is not always so. They may set their food-restriction objectives by food energy (calories) rather than by food type—for example, one may set a goal of 100 calories in a day and the food chosen to attain that number may very well be a cereal bar one day and an apple the next.
  • abuse laxatives
  • be perfectionists. A 2003 study by Sutandar-Pinnock and others analyzed the correlation between high perfectionism scores as measured by the Multidimensional Perfectionism Scale (MPS), and anorexia nervosa as measured by the Eating Disorder Inventory (EDI). The control group participated in a family study, and was indirectly involved. The experimental groups were categorized as good outcome patients, who had regained weight after treatment; and poor outcomes, who did not regain weight after treatment. The mean scores for perfectionism in both good and poor outcome patients were higher than the control group, statistically significant. The perfectionism scores for the poor outcome were statistically significantly higher than the good outcome group in 4/5 categories.

Treatment

Successful treatment of, and recovery from, anorexia is possible, but it can take many years. The earlier intervention arrests the course of the disease, the more successful the treatment is likely to be. Anorexia nervosa has the highest death rate of all mental illnesses, with as many as 20% of anorexics eventually dying of complications of the disease, usually from heart/organ failure or low levels of potassium. Once an anorexic reaches a certain weight, death becomes a very real possibility. The BMI (or body mass index) where this starts becoming a danger is generally around 12 to 12.5.(As a point of reference, a normal BMI is between 19 and 23, most "centerfold" models have a BMI of 18, and most fashion models come in at 17. An anorectic BMI is usually defined as being below 17.5.)

Health care providers

Approaches include hospitalization, psychotherapy, specialised anorexia treatment-centres, and family counseling. The prescription of psychotropic drugs such as antidepressants is also practiced. Support groups such as Overeaters Anonymous, which deals with eating disorders in general, can also be helpful.

Appropriate treatment of any present vitamin and dietary-mineral deficiencies, particularly in the common case of zinc deficiency, may be highly beneficial to the sufferer's mental and physical well being.

Anorexia is notoriously hard to treat, with sufferers often either emphatically denying that they are ill or paradoxically, accepting that they have anorexia, but seeing nothing wrong with their "lifestyle choice". This latter view is evidenced by the growing number of "pro-ana" websites and discussion groups where self-identified "anorectics" come together to reinforce their beliefs and behaviours, creating a positive feedback loop.

Another difficulty in treating anorexia nervosa is the prevalence of relapse. For some people, anorexia may be a chronic disease. In a study, within two years of hospital discharge, 35% of former anorexics had relapsed into anorexia. The greatest risk for a relapse was anywhere from six to seventeen months after discharge.

Anorexia is one of the most expensive illnesses to treat, with adequate care for the disease costing well over $100,000. Because of the high mortality rate of the disease, this is seen as a cost effective solution. Unfortunately, lengthy hospitalization is required to treat the disease adequately and many health care providers will not pay for adequate care. Hospitalization stays of 45 days are recommended for effective treatment, yet the usual stay that healthcare providers will pay for is 7 days, along with half the adequate amount of psychotherapy which is recommended.

Family and friends

The best help an anorexic can receive is unconditional love and empathy. Anorexia is fundamentally less about food than about an individual's psychological need to feel safe — in that he or she does not.

As is common among sufferers of some eating disorders, an anorexic may be very secretive about his or her disorder. Being confronted by another about it for the first time may result in feelings of panic and distress, so an informed and considerate caution is recommended. However, it is important to remember that anorexia is a dangerous disorder that signifies chronic suffering in an individual — it is important not to delay in seeking help for the person whom you believe has anorexia or bulimia. Researching the condition and consulting your local eating-disorder support network are good beginnings.

In handling an anorexic dependent, it is dangerous to "just force" him or her to eat without support. Eating for most anorexics is not as easy as "just eat" as with non-eating-disordered people. While being firm is important, keep in mind that eating things which are not considered "safe" will most likely trigger fear and panic in the sufferer.

Notable anorectics

  • Jessica Alba, has been quoted as saying, "A lot of girls have eating disorders and I did too. I got too thin. Now, I am concentrating on being normal."
  • Fiona Apple, has been quoted saying, "I definitely had an eating disorder. What was really frustrating for me was that everyone thought I was anorexic, and I wasn't. I was really depressed and self-loathing. For me, it wasn't about being thin, it was about getting rid of the bait attached to my body. A lot of it came from the self-loathing that came from being raped at the point of developing my voluptuousness. I just thought that if you had a body and if you had anything on you that would be grabbed, it would be grabbed. So I did purposely get rid of it."
  • The Barbi Twins
  • Helga Brathen, gymnast who died from anorexia.
  • Karen Carpenter, died from anorexia in 1983.
  • Sandra Dee
  • Princess Diana
  • Kate Dillon
  • Elisa Donovan
  • Patty Duke
  • Jane Fonda, while publicising her movie Coming Home, Fonda admitted to having "bulimiarexia", a dangerous binge-and-vomit cycle that nearly ruined her health. Overwhelmed by the demands of the Hollywood culture, she spent nearly 20 years in the relentless pursuit of thinness.
  • Tracey Gold
  • Christy Henrich - American gymnast who died from anorexia
  • Barbara Hutton
  • Daniel Johns of Silverchair
  • Mary-Kate Olsen, underwent treatment in 2004.
  • Scarlett Pomers, underwent treatment in 2005.
  • Christina Ricci, has commented on her anorexia by saying, "I had a brief flirtation with anorexia and when I was recovering from that, I put on a lot of weight,which was very dif- ficult for me. In a way, I was trying to get rid of my breasts. Everyone my age wanted them, so it was like, whoo-ooo. Then I started hating them. And for all of my movies, I was supposed to be younger, so I'd have to strap them down."
  • Princess Victoria
  • Ashlee Simpson, in an interview with Cosmopolitan magazine, admits her battle with anorexia during her pre-teen years.
  • Lena Zavaroni, died from bronchial pneumonia due to anorexia in 1999.

See also

References

  • Brumberg, Joan Jacob. "The Appetite as Voice." Food and Culture: A Reader. Ed. Carole Counihan and Penny van Esterik. New York: Routledge, 1997.159-179.
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