What Causes Anorexia Nervosa
Physical effects
Psychological
effects
Anorexia Nervosa
Criteria for Diagnosis
TREATING ANOREXIA
NERVOSA
Warning signs of
Anorexia
Promoting good
eating habits and a positive body image
Anorexia and the Internet
When to seek
medical advice
INTRODUCTION
Anorexia Nervosa
(AN) is an eating disorder that typically affects adolescent girls, with an
average prevalence of 0.3% in young women. [1] The
word “anorexia” means loss of appetite, a symptom in other
diseases. Most people with the diagnosis of Anorexia Nervosa are
referred to as having “anorexia,” which is technically not correct. In many
ways, people with AN do not lose their appetite, but rather are preoccupied
with food. Anorexia Nervosa is characterized by weight loss, a
distorted perception of body shape and size, and an intense fear of weight
gain. Frequently, there is also a level of denial about the
seriousness of the degree of weight loss. In this knol, when we
refer to “Anorexia” we are referring to Anorexia Nervosa (AN).
While anorexia
typically affects females, increasing numbers of males are being
diagnosed. Additionally, while patients
tend to be adolescents and young adults, increasingly patients of all ages,
including children and middle-aged adults are being seen as well. In the United States, persons suffering from
anorexia are from all different races and ethnicities.
WHAT CAUSES ANOREXIA NERVOSA
The exact cause of Anorexia Nervosa is unknown, but there are believed to be several different factors that may lead to its development. These include biological and genetic factors, psychological factors, and socio-cultural influences. Eating disorders, including anorexia, run in families, with higher rates among females with identical twins and/or first degree relatives with eating disorders. Psychological factors that have been shown to be associated with anorexia include perfectionism, anxiety, obsessive, low self-esteem, and low self-confidence. Society’s increasing emphasis on a thin body ideal may also be a factor, and may further increase low self-esteem and low confidence, resulting in dieting and further preoccupation with thinness.
Over the last few
years, the modeling world has responded to this, with at least two countries
instituting body mass index (BMI) cut offs for models to be allowed to
participate as runway models in corresponding fashion weeks. The BMI that they established as a cutoff was
18.0 which still constitutes extreme thinness for a young woman, and according
to the World Health Organization still would be defined as
“underweight.”[2] The Council for
Fashion Designers in America opted not to create BMI cut offs for models in the
US.
PHYSICAL EFFECTS of Anorexia Nervosa
Anorexia Nervosa is
a complex mental health disorder with significant physiological effects and an
associated environmental overlay. Most
of the physical effects and many of the initial alterations in cognitive
functioning are due to the degree of malnutrition.
ANOREXIA NERVOSA
CRITERIA FOR DIAGNOSIS
There is no single
blood test or study that a clinician can use to diagnose Anorexia Nervosa,
rather AN should be suspected any time an adolescent develops significant
weight loss and food avoidance. Other medical diseases should be ruled out
prior to making a diagnosis of AN, such as gastrointestinal illnesses,
endocrine problems, and certain types of cancer (see Table 1).
Table I:
DIFFERENTIAL DIAGNOSIS FOR ANOREXIA NERVOSA
Pregnancy
Inflammatory bowel
disease including Ulcerative Colitis and Crohn’s Disease
Malabsorptive
conditions including Celiac Disease
Diabetes Mellitus
Hyperthyroidism
Collagen vascular
disease including systemic lupus erythematous
Central nervous
system tumors
Cancer
Chronic infections
such as tuberculosis and human immunodeficiency virus (HIV)
Obsessive
Compulsive Disorder
Anxiety disorders
Mood disorders such
as depression
Psychosis
Substance abuse
AN is diagnosed
using a number of clinical criteria. The criteria for AN are listed in the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV):[4]
1. Refusal to maintain a minimally normal body
weight for age and height
2. Intense fear of weight gain or becoming
fat, although 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 post menarcheal females, amenorrhea,
that is the absence of at least three consecutive menstrual cycles
There are two
subtypes of AN that are described
1. 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)
2. Binge
eating/Purging subtype: 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).
Many patients may
fulfill some of the criteria for anorexia nervosa, but not all of them. They
still may struggle with problems with eating and/or problems with body
image. They may receive a diagnosis of a
“partial eating disorder” or eating disorder not otherwise specified (ed-nos).
The criteria for Eating Disorder NOS according to the DSM IV include:
1. Meet all the criteria for anorexia nervosa,
except still have normal periods
2. Meet all the criteria for anorexia nervosa,
however their weight is still within a normal range.
3. Meet all the criteria for anorexia nervosa;
however maintain a normal body image.
4. Meet all the criteria for bulimia nervosa,
except the frequency of binging and purging is less than that specified by the
DSM IV necessary to make a diagnosis of bulimia nervosa.
5. Repeatedly chew and spit out but do not
swallow their food
6. Binge-eat but do not purge (also known as
Binge Eating Disorder)
Despite a
difference in the diagnosis, the treatment will be similar, as those who suffer
from Anorexia Nervosa, Bulimia Nervosa, and Eating Disorder-NOS all share a
pre-occupation with food, as well as with body weight and shape.
TREATING ANOREXIA NERVOSA
One of the keys to
successful treatment of anorexia is early recognition of the problem and early
intervention. Children and adolescents
must be weighed and measured at every medical appointment or at a minimum once
a year. A Body Mass Index (BMI) should
be calculated and plotted on a growth curve appropriate for the adolescent’s
age and gender. BMI is a tool to screen
a person’s nutritional status and is calculated by taking the weight in
kilograms and dividing by the height (in meters) squared (BMI = kg/m2). [5],[6]
MULTIDISCIPLINARY
TREATMENT TEAM
Successful
treatment typically requires a multidisciplinary team knowledgeable in the care
of patients with eating disorders. The
team should include:
• A physician who can monitor weight, vital
signs and other consequences due to malnutrition;
• A dietician or nutritionist who can assist
with meal planning, and weight restoration; and
• A therapist who is knowledgeable about
treating eating disorders.
GOALS OF TREATMENT of Anorexia Nervosa
The goals of
treatment include immediate weight restoration (returning the patient to a
healthy, stable weight). Weight restoration is the critical first step to
enable the patient to be capable of benefiting from psychological treatment.
Psychological treatment aims to improve the patient’s body distortion and
intense fear of becoming fat in addition to symptoms of anxiety and or
depression that may also exist. In the
long term, additional goals include resumption of normal menstrual periods, and
improved psychological functioning.
Nutritional
treatment typically occurs with the guidance of a dietician The goal is to resume healthy eating habits
and patterns. A dietician may develop a meal plan for a patient to ensure they
are obtaining optimal calories in addition to resuming well balanced eating
habits. Patients will typically need to
increase the variation in the types of food they are eating. As patients are improving their nutrition and
restoring their weight, they often require zinc supplementation and typically
benefit from a multivitamin and calcium and vitamin D supplementation.
For adolescents
with AN, family therapy is an effective psychotherapeutic
treatment.[7]Typically treatment occurs as an outpatient. Treatment may require
inpatient hospitalization for medical stabilization. At times, an intensive
outpatient or partial hospitalization may be more beneficial. For patients who are not responding to
outpatient treatment but who are medically stable, residential treatment
programs may be necessary.
The benefits of
psychotropic medication, including antidepressants and atypical neuroleptic
medications, is unclear, and further research is necessary..[8],
[9]Antidepressant medications, particularly selective serotonin reuptake
inhibitors (SSRIs)may be beneficial in treating co-existing symptoms of
depression or obsessive-compulsive disorder.
Malnutrition itself may worsen symptoms of anxiety, depression, and
obsessive behavior. It is important to
reevaluate symptoms throughout the treatment and recovery process. If symptoms
persist following weight restoration, medications may be more effective in treating
those symptoms. Depression, anxiety, and
substance abuse are the most common other mental health disorders that occur
among people with anorexia.
REFEEDING SYNDROME
At times patients
may be severely malnourished, requiring acute medical hospitalization. These
patients will require being refed in hospital under close surveillance to
monitor for “refeeding syndrome.” When the body is severely malnourished, it is
in a catabolic state, when the tissues are breaking down into simpler metabolic
constituents. When a patient begins to
eat again, there is a surge of insulin as the body switches to an anabolic
state, when the body’s chemical processes are constructive, or synthesizing
tissues, enzymes and other components.
This surge of insulin can cause shifts in electrolytes, in particular
phosphorous, potassium, and magnesium as well as shifts of sodium and water. The results can lead to cardiac arrhythmias,
breakdown of muscle, edema (swelling in the hands and feet), delirium, and even
death.
LONG TERM OUTCOMES
Generally,
adolescents have better outcomes than adults, which may be due to a shorter
length of symptoms among adolescents.
Other good prognostic factors include: early identification and entry
into treatment, short duration of symptoms, age less than 14 years, no binging
and purging (the restricting subtype of anorexia rather than the binge/purge
subtype), and no other mental health disorder (such as depression, anxiety, or
substance abuse).[10] Fifty percent of
adolescents are thought to have a good outcome; however, recovery can take many
years.[11]
The leading causes
of death due to anorexia are by suicide, or secondary to medical complications
of malnutrition/starvation. Mortality
rates range from 2% to 8%.
WARNING SIGNS OF ANOREXIA
• Someone who appears to becoming thinner
and thinner
• Someone who is not gaining weight in a
reasonable and expected manner as they are going through puberty
• Complains about being fat when obviously
is not
• Skipping meals
• Making frequent excuses for not
eating-“I’m not hungry, I’m too busy, I don’t eat that…”
• Someone who continues to diet or lose
weight even though he/or she is not overweight
• May complain frequently of feeling cold,
when others do not
• Complains about feeling full even after
only eating a small amount of food
• Socially withdraws from activities,
particularly activities around food (like going out for dinner or eating with
their family)
• Repeatedly weighs themselves
• Engages in prolonged periods of exercise
even when feeling tired or weak
• Obsessive calorie counting
• Eating rituals such as eating the same
food for lunch every day, or needing to cut food into tiny pieces and pushing
it around the plate rather than eating it
• Collecting recipes and cooking for others
while finding excuses to avoid eating
• Becomes disgusted with foods that were
previously favorites
PROMOTING GOOD
EATING HABITS AND A POSITIVE BODY IMAGE
1. Parents should be good role models for
their children, with healthy eating and exercise habits
2. Don’t make negative comments about your own
body or anyone else’s
3. Recognize that there are a range of body
shapes and sizes
4. Don’t judge a person based on their weight
or size, it does not reflect the type of person they are
5. Encourage family meals
6. Encourage regular healthy exercise
ANOREXIA AND THE INTERNET
The majority of Web
sites provide a medical view of anorexia, which defines anorexia as a mental
health disorder that can be cured. These
Web sites and online communities are run by professionals in addition to those
suffering with an eating disorder or a history of an eating disorder. These resources may provide information and
support to current sufferers and their friends and family.
Additionally, there
is another group of Web sites, which argue that anorexia is not an illness but
rather a “lifestyle choice.” These
pro-anorexia or pro-ana Web sites may contain dangerous and unhealthy
information including weight loss-tips and support of the perpetuation of
eating disorders. These Web sites have
an unclear impact, however they may foster the development of an eating disorder
in a vulnerable adolescent or young adult. [12]
