Anorexia Nervosa

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What is anorexia nervosa?

Anorexia nervosa (or simply anorexia) is an eating disorder in which people intentionally starve themselves. It causes extreme weight loss, which the National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH), defines as at least 15 percent below the individual's normal body weight.

Food and weight become obsessions. Compulsiveness may cause strange eating rituals or the refusal to eat in front of others. It is not uncommon for people with anorexia to collect recipes and prepare gourmet feasts for family and friends, but not partake in the meals themselves. They may also adhere to strict exercise routines to keep off weight.

What causes anorexia nervosa?

The cause of anorexia nervosa is not known. Anorexia usually begins as innocent dieting behavior, but gradually progresses to extreme and unhealthy weight loss. Social attitudes toward body appearance, family influences, genetics, and neurochemical and developmental factors are considered possible contributors to the cause of anorexia. Persons who develop anorexia are more likely to come from families with a history of weight problems, physical illness, and other mental health problems, such as depression or substance abuse. Further, often persons with the disorder come from families that are challenged by appropriate problem solving, being too rigid, overly-critical, intrusive, and overprotective. Persons with anorexia may also be dependent, immature in their emotional development, and are likely to isolate themselves from others. Other mental health problems such as anxiety disorders or affective disorders are commonly found in persons with anorexia.

Who is affected by anorexia nervosa?

The occurrence of anorexia nervosa has increased over the past 20 years. It is estimated to occur in one out of every 100 females between the ages of 16 and 18 years old. Five to 10 percent of teens diagnosed with anorexia are males. Initially found mostly in upper- and middle-class families, anorexia is now found in all socioeconomic groups and a variety of ethnic and racial groups.

What are some common characteristics of persons with anorexia nervosa?

Most people with eating disorders share certain personality traits and use abnormal eating rituals as a means of handling stress and anxiety. These personality traits often include, but are not limited to, the following:

  • low self-esteem
  • feelings of helplessness
  • fear of becoming fat

Persons with anorexia nervosa:

  • rarely break rules or disobey.
  • often keep their feelings to themselves.
  • tend to be perfectionists, good students, and excellent athletes.

People with anorexia usually follow the wishes of others, and have not learned how to cope with the problems typical of adolescence, growing up, and becoming independent. It is believed that they restrict food - particularly carbohydrates - to gain a sense of control in some/one area of their lives. Controlling their weight appears to offer two advantages:

  • taking control of their bodies
  • gaining approval from others

What are the different types of anorexia?

There are two subgroups of anorexic behavior aimed at reducing caloric intake, including the following:

  • restrictor type - severely limits the intake of food, especially carbohydrates and fat containing foods.
  • bulimia (also called binge-eating/purging type) - eats in binges and then induces vomiting and/or takes large amounts of laxatives or other cathartics (medications, through their chemical effects, that serve to increase the clearing of intestinal contents).

What are the symptoms of anorexia nervosa?

The following are the most common symptoms of anorexia. However, each individual may experience symptoms differently. Symptoms may include:

  • low body weight (less than 85 percent of normal weight for height and age)
  • intense fear of becoming obese , even as individual is losing weight
  • distorted view of one's body weight, size, or shape; sees self as too fat, even when very underweight; expresses feeling fat, even when very thin
  • refuses to maintain minimum normal body weight
  • in females, absence of three menstrual cycles without another cause
  • excessive physical activity
  • denies feelings of hunger
  • preoccupation with food preparation
  • bizarre eating behaviors

The following are the most common physical symptoms associated with anorexia - often that result from starvation and malnourishment. However, each individual may experience symptoms differently. Symptoms may include:

  • dry skin that when pinched and released, stays pinched
  • dehydration
  • abdominal pain
  • constipation
  • lethargy
  • fatigue
  • intolerance to cold temperatures
  • emaciation
  • development of lanugo (fine, downy body hair)
  • yellowing of the skin

Persons with anorexia may also be socially withdrawn, irritable, moody, and/or depressed. The symptoms of anorexia nervosa may resemble other medical problems or psychiatric conditions. Always consult your physician for a diagnosis.

How is anorexia nervosa diagnosed?

Parents, family members, spouses, teachers, coaches, and instructors may be able to identify an individual with anorexia, although many persons with the disorder initially keep their illness very private and hidden. A detailed history of the individual's behavior from family, parents, and teachers, clinical observations of the person's behavior, and, sometimes, psychological testing contribute to the diagnosis. Family members who note symptoms of anorexia in a loved one can help by seeking an evaluation and treatment early. Early treatment can often prevent future problems.

Anorexia, and the malnutrition that results, can adversely affect nearly every organ system in the body, increasing the importance of early diagnosis and treatment. Anorexia can be fatal. Consult your physician for more information.

Treatment for anorexia nervosa:

Specific treatment for anorexia nervosa will be determined by your physician based on:

  • your age, overall health, and medical history
  • extent of the symptoms
  • your tolerance for specific medications, procedures, or therapies
  • expectations for the course of the condition
  • your opinion or preference

Anorexia is usually treated with a combination of individual therapy, family therapy, behavior modification, and nutritional rehabilitation. Treatment should always be based on a comprehensive evaluation of the individual and family. Individual therapy usually includes both cognitive and behavioral techniques. Medication (usually antidepressants) may be helpful if the person with anorexia is also depressed. The frequent occurrence of medical complications and the possibility of death during the course of acute and rehabilitative treatment requires both your physician and a nutritionist to be active members of the management team. Families play a vital supportive role in any treatment process.

Possible complications of anorexia nervosa:

Medical complications that may result from anorexia include, but are not limited to, the following:

  • cardiovascular (heart)
    While it is difficult to predict which anorexic patients might have life-threatening cardiac consequences that result from their illness, up to 95 percent of hospitalized anorexic patients have been found to have low heart rates. Myocardial (heart muscle) damage that can occur as a result of changes in the heartbeat, or repeated vomiting, may be life threatening. Common cardiac complications that may occur include the following:
    • arrhythmias (a fast, slow, or irregular heartbeat)
    • bradycardia (slow heartbeat)
    • hypotension (low blood pressure)
  • hematological (blood)
    An estimated one-third of anorexic patients have mild anemia (low red blood cell count). Leukopenia (low white blood cell count) occurs in up to 50 percent of anorexic patients.
  • gastrointestinal (stomach and intestines)
    Normal movement in intestinal tract often slows down with very restricted eating and severe weight loss. Gaining weight and some medications help to restore normal intestinal motility.
  • renal (kidney)
    Dehydration often associated with anorexia results in highly concentrated urine. Polyuria (increased production of urine) may also develop in anorexic patients when the kidneys ability to concentrate urine decreases. Renal changes usually return to normal with the restoration of normal weight.
  • endocrine (hormones)
    Amenorrhea (cessation of the menstrual cycle) is one of the hallmark symptoms of anorexia, when a menstrual period is missed for three or more months without any other underlying cause. Amenorrhea often precedes severe weight loss and continues after normal weight is restored. Reduced levels of growth hormones are sometimes found on anorexic patients and may explain growth retardation sometimes seen in anorexic patients. Normal nutrition usually restores normal growth.
  • skeletal (bones)
    Persons with anorexia are at an increased risk for skeletal fractures (broken bones). When the onset of anorexic symptoms occurs before peak bone formation has been attained (usually mid to late teens), a greater risk of osteopenia (decreased bone tissue) or osteoporosis (bone loss) exists. Bone density is often found to be low in females with anorexia, and low calcium intake and absorption is common.

Biochemistry and eating disorders:

To understand eating disorders, researchers have studied the neuroendocrine system, which is made up of a combination of the central nervous and hormonal systems.

The neuroendocrine system regulates multiple functions of the mind and body. It has been found that many of the following regulatory mechanisms may be, to some degree, disturbed in persons with eating disorders:

  • sexual function
  • physical growth and development
  • appetite and digestion
  • sleep
  • heart function
  • kidney function
  • emotions
  • thinking
  • memory

Eating disorders and depression:

Many people with eating disorders also appear to suffer from depression, and is believed that there may be a link between these two disorders. For example:

  • In the central nervous system, chemical messengers known as neurotransmitters control hormone production. The neurotransmitters serotonin and norepinephrine, which function abnormally in people who have depression, have been discovered to also have decreased levels in both acutely-ill anorexia and bulimia patients, and long-term recovered anorexia patients.
  • Research has shown that some patients with anorexia may respond well to antidepressant medication that affects serotonin function in the body.
  • People with anorexia, or certain forms of depression, seem to have higher than normal levels of cortisol, a brain hormone released in response to stress. It has been shown that the excess levels of cortisol in both persons with anorexia and in persons with depression are caused by a problem that occurs in, or near, the hypothalamus of the brain.
  • Biochemical similarities have been discovered between people with eating disorders and obsessive-compulsive disorder (OCD), and patients with OCD frequently have abnormal eating behaviors.
  • The hormone vasopressin is another brain chemical found to be abnormal in people with eating disorders and OCD. Levels of this hormone are elevated in patients with OCD, anorexia, and bulimia.

Genetic/environmental factors related to eating disorders:

Because eating disorders tend to run in families, and female relatives are the most often affected, genetic factors are believed to play a role in the disorders.

But, other influences, both behavioral and environmental, may also play a role. Consider these facts from the National Institute of Mental Health:

  • According to one recent study, mothers who are overly concerned about their daughters' weight and physical attractiveness may put their daughters at increased risk of developing an eating disorder. In addition, girls with eating disorders often have a father and/or brother(s) who are overly critical of their weight.
  • Although most victims of anorexia and bulimia are adolescent and young adult women, these illnesses can also strike men and older women.
  • Anorexia and bulimia are found most often in Caucasians, but these illnesses also affect African Americans and other races.
  • People pursuing professions or activities that emphasize thinness - such as modeling, dancing, gymnastics, wrestling, and long-distance running - are more susceptible to these disorders.
  • In contrast to other eating disorders, one-third to one-fourth of all patients with binge eating disorder are men. Preliminary studies also show that the condition occurs equally among African Americans and Caucasians.

Prevention of anorexia nervosa:

Preventive measures to reduce the incidence of anorexia are not known at this time. However, early detection and intervention can reduce the severity of symptoms, enhance the individual's normal growth and development, and improve the quality of life experienced by persons with anorexia nervosa. Encouraging healthy eating habits and realistic attitudes toward weight and diet may also be helpful.