Anorexia Nervosa

What is anorexia nervosa?

Anorexia nervosa, commonly referred to simply as anorexia, is one type of eating disorder. More importantly, it is also a psychological disorder. Anorexia is a condition that goes beyond concern about obesity or out-of-control dieting. A person with anorexia often initially begins dieting to lose weight. Over time, the weight loss becomes a sign of mastery and control. The drive to become thinner is actually secondary to concerns about control and/or fears relating to one's body. The individual continues the ongoing cycle of restrictive eating, often accompanied by other behaviors such as excessive exercising or the overuse of diet pills to induce loss of appetite, and/or diuretics, laxatives, or enemas in order to reduce body weight, often to a point close to starvation in order to feel a sense of control over his or her body. This cycle becomes an obsession and, in this way, is similar to an addiction.

Who is at risk for anorexia nervosa?

Approximately 95% of those affected by anorexia are female, most often teenage girls, but males can develop the disorder as well. While anorexia typically begins to manifest itself during early adolescence, it is also seen in young children and adults. In the U.S. and other countries with high economic status, it is estimated that about one out of every 100 adolescent girls has the disorder. Caucasians are more often affected than people of other racial backgrounds, and anorexia is more common in middle and upper socioeconomic groups. According to the U.S. National Institute of Mental Health (NIMH), other statistics about this disorder include the fact that an estimated 0.5%-3.7% of women will suffer from this disorder at some point in their lives. About 0.3% of men are thought to develop anorexia in their lifetimes
Many experts consider people for whom thinness is especially desirable, or a professional requirement (such as athletes, models, dancers, and actors), to be at risk for eating disorders such as anorexia nervosa. Health-care professionals are usually encouraged to present the facts about the dangers of anorexia through education of their patients and of the general public as a means of preventing this and other eating disorders.

What causes anorexia nervosa?

At this time, no definite cause of anorexia nervosa has been determined. However, research within the medical and psychological fields continues to explore possible causes.
Studies suggest that a genetic (inherited) component may play a more significant role in determining a person's susceptibility to anorexia than was previously thought. Researchers are currently attempting to identify the particular gene or genes that might affect a person's tendency to develop this disorder, and preliminary studies suggest that a gene located at chromosome 1p seems to be involved in determining a person's susceptibility to anorexia nervosa.
Other evidence had pinpointed a dysfunction in the part of the brain, the hypothalamus (which regulates certain metabolic processes), as contributing to the development of anorexia. Other studies have suggested that imbalances in neurotransmitter (brain chemicals involved in signaling and regulatory processes) levels in the brain may occur in people suffering from anorexia.
Feeding problems as an infant, a general history of undereating, and maternal depressive symptoms tend to be risk factors for developing anorexia. Other personal characteristics that can predispose an individual to the development of anorexia include a high level of negative feelings and perfectionism. For many individuals with anorexia, the destructive cycle begins with the pressure to be thin and attractive. A poor self-image compounds the problem. People who suffer from any eating disorder are more likely to have been the victim of childhood abuse.
While some professionals remain of the opinion that family discord and high demands from parents can put a person at risk for developing this disorder, the increasing evidence against the idea that families cause anorexia has mounted to such an extent that professional mental-health organizations no longer ascribe to that theory. Possible factors that protect against the development of anorexia include high maternal body mass index (BMI) as well as personal high self-esteem.

How is anorexia nervosa diagnosed?

Anorexia nervosa can be a difficult disorder to diagnose, since individuals with anorexia often attempt to hide the disorder. Denial and secrecy frequently accompany other symptoms. It is unusual for an individual with anorexia to seek professional help because the individual typically does not accept that she or he has a problem (denial). In many cases, the actual diagnosis is not made until medical complications have developed. The individual is often brought to the attention of a professional by family members only after marked weight loss has occurred. When anorexics finally come to the attention of the health-care professional, they often lack insight into their problem despite being severely malnourished and may be unreliable in terms of providing accurate information. Therefore, it is often necessary to obtain information from parents, a spouse, or other family members in order to evaluate the degree of weight loss and extent of the disorder. Health professionals will sometimes administer questionnaires for anorexia as part of screening for the disorder.
Warning signs of developing anorexia or one of the other eating disorders include excessive interest in dieting or thinness. One example of such interest includes a movement called "thinspiration," which promotes extreme thinness as a lifestyle choice rather than as a symptom of illness. There are a variety of web sites that attempt to inspire others toward extreme thinness by featuring information on achieving that goal, photos of famous, extremely thin celebrities, and testimonials, as well as before and after pictures of individuals who ascribe to extreme thinness.
The actual criteria for anorexia nervosa are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
There are four basic criteria for the diagnosis of anorexia nervosa that are characteristic:

1. The refusal to maintain body weight at or above a minimally normal weight for age and height (maintaining a body weight less than 85% of the expected weight)
2. An intense fear of gaining weight or becoming fat, even though the person is underweight
3. Self-perception that is grossly distorted, excessive emphasis on body weight in self-assessment, and weight loss that is either minimized or not acknowledged completely
4. In women who have already begun their menstrual cycle, at least three consecutive periods are missed (amenorrhea), or menstrual periods occur only after a hormone is administered.

The DSM-IV-TR further identifies two subtypes of anorexia nervosa. In the binge-eating/purging type, the individual regularly engages in binge eating or purging behavior which involves self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode of anorexia. In the restricting type, the individual severely restricts food intake but does not regularly engage in the behaviors seen in the binge-eating type.

What are anorexia symptoms and signs (psychological and behavioral)?

Anorexia can have dangerous psychological and behavioral effects on all aspects of an individual's life and can affect other family members as well.

• The individual can become seriously underweight, which can lead to depression and social withdrawal.
• The individual can become irritable and easily upset and have difficulty interacting with others.
• Sleep can become disrupted and lead to fatigue during the day.
• Attention and concentration can decrease.
• Most individuals with anorexia become obsessed with food and thoughts of food. They think about it constantly and become compulsive about eating rituals. They may collect recipes, cut their food into tiny pieces, prepare elaborate calorie-laden meals for other people, or hoard food. Additionally, they may exhibit other obsessions and/or compulsions related to food, weight, or body shape that meet the diagnostic criteria for an obsessive compulsive disorder.
• Other psychiatric problems are also common in people with anorexia nervosa, including affective (mood) disorders, anxiety disorders, and personality disorders.
• Generally, individuals with anorexia are compliant in every other aspect of their life except for their relationship with food. Sometimes, they are overly compliant, to the extent that they lack adequate self-perception. They are eager to please and strive for perfection. They usually do well in school and may often overextend themselves in a variety of activities. The families of anorexics often appear to be "perfect." Physical appearances are important to the anorexia sufferer. Performance in other areas is stressed as well, and they are often high achievers in many areas.
• While control and perfection are critical issues for individuals with anorexia, aspects of their life other than their eating habits are often found to be out of control as well. Many have, or have had at some point in their lives, addictions to alcohol, drugs, or gambling. Compulsions involving sex, exercising, housework, and shopping are not uncommon. In particular, people with anorexia often exercise compulsively to speed the weight-loss process.
• Symptoms of anorexia in men tend to co-occur with other psychological problems and more commonly follow a period of being overweight than in women. Men with anorexia also tend to be more likely to have a distorted body image.
• Compared to symptoms in men, symptoms of anorexia in women tend to more frequently include a general displeasure with their body and a possibly stronger desire to be thin. Women with anorexia also tend to experience more perfectionism and cooperativeness.

Due to the growth and development inherent during childhood and adolescence, symptoms and signs of anorexia in children and teenagers can include a slowing of the natural increase in height or a slowed increase in development of other body functions.
All of these features can negatively affect one's daily activities. Diminished interest in previously preferred activities can result. Some individuals also have symptoms that meet the diagnostic criteria for a major depressive disorder.

What are anorexia symptoms and signs (physical)?

Most of the medical complications of anorexia nervosa result from starvation. Few organs are spared the progressive deterioration brought about by anorexia.

• Heart and circulatory system: Although not life-threatening, an abnormally slow heart rate (bradycardia) and unusually low blood pressure (hypotension) are frequent manifestations of starvation and are commonly associated with anorexia. Of greater significance are disturbances in the heart rhythm (arrhythmia). A reduction in the work capacity of the heart is associated with severe weight loss and starvation.
• Gastrointestinal complications are also associated with anorexia. Constipation and abdominal pain are the most common symptoms. The rate at which food is absorbed into the body is slowed down. Starvation and overuse of laxatives can seriously disrupt the body's normal functions involved in the elimination process. While liver function is generally found to be normal, there is evidence that some individuals with anorexia develop changes in enzyme levels and overall damage to the liver.
• The glandular (endocrine) system in the body is profoundly affected by anorexia. The complex physical and chemical processes involved in the maintenance of life can be disrupted, with serious consequences. Disturbances in the menstrual cycle are frequent, and secondary amenorrhea (absence of menstrual periods) affects about 90% of adolescent girls with anorexia. Menstrual periods typically return with weight gain and successful treatment. Hormonal imbalances are found in men with anorexia as well. Continual restrictive eating can trick the thyroid into thinking that the body is starving, causing it to slow down in an attempt to preserve calories. When anorexia occurs in a person who also has diabetes mellitus (a tendency toward very high blood sugar levels), the risk of death is higher than in people who have either anorexia or diabetes mellitus alone.
• Kidney (renal) function may appear normal. However, there are significant changes in kidney function in many people with anorexia, resulting in increased or decreased urination or potentially fatal potassium deficiency. Diabetes insipidus, characterized by excessive urination and extreme thirst, has also been seen in anorexia.
• Bone density loss (osteopenia or thinning of the bones) is a significant complication of anorexia, since women acquire 40%-60% of their bone mass during adolescence. Studies have shown that bone loss can occur fairly rapidly in girls with anorexia. While some studies have shown that bone density may be restored if overall health improves and anorexia is successfully treated, other studies suggest that an increased risk for fracture may persist later in life.
• Anorexics who use a large quantity of laxatives or who frequently vomit are in danger of electrolyte imbalance, which can have life-threatening consequences.
• Anemia is frequently found in anorexic patients. In addition to having fewer red blood cells, people with anorexia tend to have lower numbers of white blood cells, which play a major role in protecting the body from developing infections. Suppressed immunity and a high risk for infection are suspected but not clinically proven.
• Contrary to what might be expected, anorexia nervosa is associated with a high total cholesterol levels.
• Physical symptoms, other than the obvious loss of weight, can be seen. Anorexia can cause dry, flaky skin that takes on a yellow tinge. Fine, downy hair grows on the face, back, arms, and legs. Despite this new hair growth, loss of hair on the head is not uncommon. Nails can become brittle. Frequent vomiting can erode dental enamel and eventually lead to tooth loss. People with anorexia might also develop trouble maintaining a consistent body temperature.

What is the treatment for anorexia nervosa?

Anorexia may be treated in an outpatient setting or hospitalization may be necessary. For an individual with severe weight loss that has impaired organ function, hospital treatment must initially focus on correction of malnutrition, and intravenous feeding or tube feeding that goes past the mouth may be required. A gain of between 1 to 3 pounds per week is a safe and attainable goal when malnutrition must be corrected. Sometimes weight gain is achieved using schedules for eating, decreased physical activity, and increased social activity, either on an inpatient or outpatient basis. For individuals who have suffered from anorexia for several years, the goals of treatment may need to be achieved more slowly in order to prevent the anorexia sufferer from relapsing as a result of being overwhelmed by treatment.
The overall treatment of anorexia, however, must focus on more than weight gain. There are a variety of treatment approaches dependent upon the resources available to the individual. Because of increasing insurance restrictions, many patients find that a short hospitalization followed by a day treatment program is an effective alternative to longer inpatient programs. Most individuals, however, initially seek outpatient treatment involving psychological as well as medical intervention. It is common to engage a multidisciplinary treatment team consisting of a medical-care provider, a dietician or nutritionist, and a mental-health-care provider.
Different kinds of psychological therapy have been employed to treat people with anorexia. Individual therapy, cognitive behavior therapy, group therapy, and family therapy have all been successful in the treatment of anorexia. In adolescents, research shows that the Maudsley model of family therapy can be particularly effective in treating this disorder in this population. In contrast to many past approaches to treatment, the Maudsley model approaches the family of the individual with anorexia as part of the solution rather than part of the reason their loved one has the disorder. With ongoing specific guidance from the professional mental-health team, this approach has the family actively help their loved one eat in a more healthy manner.
Any appropriate treatment approach addresses underlying issues of control, perfectionism, and self-perception. Family dynamics are explored. Nutritional education provides a healthy alternative to weight management for the patient. Group counseling or support groups may assist the individual in the recovery process. The ultimate goal of treatment should be for the individual to accept herself/himself and lead a physically and emotionally healthy life.
While no medications have been identified that can definitively reduce the compulsion to starve themselves, olanzapine (Zyprexa, Zydis), risperidone (Risperdal), and quetiapine (Seroquel) are medications that are also used as mood stabilizers and to treat schizophrenia that may be useful in treating anorexia. These medications may also help increase weight and to manage some of the emotional symptoms like anxiety and depression that can accompany anorexia. Some of the selective serotonin reuptake inhibitor (SSRI) antidepressant drugs have been shown to be helpful in weight maintenance after weight has been gained, as well as having beneficial effects on the mood and anxiety symptoms that may be associated with the condition.