Anorexia nervosa is a psychological disorder characterised by self-starvation , very often excessive exercise, and weight loss. Anorexia nervosa is subcategorised into restrictive (starvation) and purging (including bingeing and purging or excessive exercise). While it has psychological origins, it also obviously affects physical wellbeing.
Anorexia nervosa usually begins with a desire to diet and lose weight. It may be triggered by an event such as the end of a relationship or the death of someone significant . As many as 60% of patients suffering from anorexia nervosa have been sexually abused; the disorder following such a traumatic event. It may include the need to exert control over feelings the person feels unable to control, by instead controlling food intake.
Anorexic people are obsessed about food and are terrified by the thought of gaining weight. They eventually do not eat enough to sustain a healthy body weight. In addition, they suffer from a distorted body image, experiencing themselves as overweight when they are really thin. One must not confuse weight and size. Anorexics see themselves to be overweight. In reality they are thin or emaciated and underweight.
Anorexic people may behave bizarrely about food, for example refusing to eat in front of other people, or hiding it around the house. Someone may be greatly interested in the preparation and cooking of food, but will not eat it. They may also cut out entire food groups, especially those considered high in fat or carbohydrates. Anorexic people may engage in excessive exercise patterns, binge eating, induced vomiting or use of laxatives . Diuretics are also abused. Appetite suppressants (most of which include pseudoephadrine) are frequently used to curb appetite.
People with anorexia nervosa will usually not acknowledge that there is something wrong with their eating patterns. This is typical in the early phase when the sufferer is still in denial. Anorexia is like an addictive state. It serves the purpose of blunting the sufferer from her/his uncomfortable emotional feelings, just as alcohol and drugs do in the chemical addict, and once the individual has started dieting and losing weight, it is very difficult for them to stop. The disorder may lead to various medical complications. It is potentially very dangerous and, if not treated appropriately, may result in death.
The factors that lead to anorexia nervosa are complex and not clearly understood. It is widely acknowledged that psychological, social, biological, cultural and familial factors all play a role in the development of the disorder. There has recently been some argument that it has a genetic or organic basis, but there is little supportive evidence and research continues. The above mentioned factors probably interact and contribute to the development of anorexia nervosa in susceptible individuals.
It is likely that the media plays a pivotal role in promoting reinforcing the development of anorexia nervosa. Young women are faced with a barrage of media propaganda suggesting what the ideal body is. Models are always slim and often waif-like. These images reinforce social stereotypes about what is beautiful. One should, however, accept that the media is often only the messenger portraying trends in society.
Anorexia nervosa is more likely to start when a young person is going through a difficult life stage . The very high risk age for developing anorexia nervosa is 16-24 years, the earlier group going through many physical and social changes associated with increased anxiety levels. People suffering from anorexia often have a poor self-image and believe they don’t deserve love. This is coupled with pressure to be thin and attractive, often as a means to feel accepted by their peer group. The initial weight loss from dieting often elicits approval from family and friends, which makes the person feel good and reinforces dieting.
Certain family patterns place an individual at risk for anorexia. Anorexic people often come from families that over-value high achievement. They are therefore often over-achievers who are perfectionists, hard-working, ambitious and compulsive about many aspects of their lives.
Families of anorexic people are often overly involved with each other’s lives and too dependent on each other. Independence is not fostered and so the child may fear growing up. Starving the body and preventing its development may fulfil an often unconscious desire to remain a child. A child in such a family may also fear their emerging sexuality and try to prevent this by remaining thin. The condition may also occur in families where parents are under-involved in or neglectful of their children. This is often the case of young professional families with parents being dual income earners. It may also occur in families with addiction; alcoholism and also eating disorders are significantly evident amongst parents.
The following symptoms are present in confirmed cases of anorexia:
- Refusal to maintain body weight at or above 85% of normal for a person of that age and height
- An intense fear of gaining weight or becoming fat, even though underweight
- A distorted body image, with a perception of being overweight even when thin
- Being thin or emaciated and underweight
- Absence of at least three consecutive menstrual cycles (unless on a contraceptive pill)Other features which may be present include:
- Vomiting and abuse of laxatives in an attempt to control weight
- Use of appetite suppressants. Pseudophadrine is highly addictive in itself
- Strict rules about eating
- Obsessive compulsive rituals
- Excessive exercise
- An abnormal preoccupation with food
- Lack of sexual desire
- Denial of the problem
- Decline in day-to-day functioning
- Efforts to hide or disguise their condition, such as wearing bulky and concealing clothing, vomiting in private, and hiding food
- Cognitive fall-off. Substance abuse (cocaine and speed is common) is quite often evident. Sometimes alcohol can be the exclusive caloric intake.
Anorexia can have a serious impact on all areas of an individual’s life. Starvation can lead to effects similar to depression. The individual is likely to be very tired, suffer from decreased attention and concentration and may lose interest in previously enjoyed activities. They may withdraw socially and interpersonal and close intimate relationships may suffer.
Associated medical complications related to starvation may include:
- Abnormally low heart rate
- Dry, sallow skin
- Fine downy hair on face and arms, called lanugo hair, which is the body’s attempt to preserve warmth
- Excessive energy
- Cold intolerance – especially sensitivity in the hands and feet
- Low blood pressure or light-headedness
- Gastrointestinal problems such as constipation and abdominal pain
- Hormonal disturbances
- Swelling of joints
- Brittleness of hair and nails
In severe cases of semi-starvation, complications may include:
- Irregular heart rate
- Impaired kidney functioning
- Severely low blood pressure
- Erosion of dental enamel because of repeated vomiting
- Brittleness of bones (osteoporosis)
The complications of anorexia can be fatal.
Accurate South African statistics on the prevalence of anorexia are not available. It is far more common among women than men (90% of suffers are women) and usually strikes during early adolescence and young adulthood. In America about 0.5 to one percent of girls aged 13 to 19 years have anorexia nervosa.
Anorexia is considered a chronic disorder. Its course varies: there may be spontaneous recovery without treatment, recovery after any of a variety of treatments, a fluctuating course of weight gains followed by relapses, or a gradually deteriorating course resulting in death.
The prognosis for recovery is better if the disorder is detected and treated early, before it becomes entrenched. People with milder cases who do not require hospitalisation are also more likely to recover. Approximately 70 to 80% of people with eating disorders experience some success with treatment.
However, anorexia is often quite resistant to treatment and relapses are common. About 50% of anorexic people get back to their normal weight, but almost half of them continue to suffer from other symptoms such as depression, anxiety or difficulty with close interpersonal and familial relationships . Some sufferers will enter remission, but relapse into a bulimic condition or develop a drug (narcotic) dependency.
Anorexia nervosa often starts as a normal diet and develops into obsessive weight-watching behaviour. Similarly, simply skipping one course such as dessert can turn into skipping full meals. There is no way to determine which dieting women are more at risk. Restrictive diets that lead to rapid weight loss (more than 1 to 1.5 kilograms per week) are more likely to lead to anorexia nervosa development. Gentle weight loss diets with sufficient caloric intake (>1400 calories per day) are less likely to lead to disordered eating.
Anorexia may start after a stressful event in the person’s life. Even a seemingly harmless comment about someone’s weight or physical appearance may trigger the disorder. Changes in an individual’s body, such as those occurring during puberty, may lead to concerns about body image and ultimately to anorexia.
When to see a doctor
Call your doctor if someone you know:
- Loses a substantial amount of weight or shows rapid weight loss.
- Refuses to eat regularly.
- Diets excessively.
- Constantly feels fat when she or he is actually thin.
- Exercises excessively to lose weight.
- Is preoccupied with food and obsessesive about calorie intake.
- Uses laxatives, diuretics or diet pills, or vomits after eating.
- Is dizzy, faints or is very listless.
- Has an irregular heartbeat.
- Has trouble sleeping and is hyperactive.
- Denies that there is a problem.
- Psychiatric complications such as depression are present.
It is often difficult to diagnose this condition, as anorexic people do not like or are unable to admit that there is anything wrong and will try to disguise the disorder. Apart from those who definitely have anorexia, many more adolescents and young women show some of the symptoms of anorexia and may be on the way to developing the disorder.
Careful attention must be paid to the warning signs. Anorexia nervosa should be suspected when a young woman experiences an unexpected weight loss, especially where she continues to complain of feeling fat, no matter how much weight she is losing.
The doctor can conduct blood and urine tests to rule out other potential causes of weight loss.
There may be overlap between anorexia nervosa and another eating disorder, bulimia nervosa. Bulimia nervosa is a condition characterised by binge eating combined with inappropriate strategies to prevent weight gain, such as vomiting, laxative use or excessive exercise. Many anorexic people develop bulimic tendencies and will go through periods of binge eating and vomiting or laxative abuse. Typically, an anorexic person loses control and binges because of extreme hunger. Vomiting or laxative abuse may also occur when the individual tries to re-engage in normal eating habits.
The primary aim of the treatment of anorexia is to address the underlying psychological and interpersonal factors and to restore weightloss in a caring, humane manner. It is critical that weight restoration be the primary objective, the eatiological factors being important to explore only once the weight is being restored and normal eating habits are established. Exploring underlying causes too early can exacerbate the anorexic behaviour. Treatment is most effective when it consists of a multidisciplinary approach including psychotherapy, nutritional advice and medical monitoring.
It is important to develop an individualised treatment programme based on the person’s specific needs. Treatment varies depending on the stage of the illness and the person’s willingness to participate. Hospitalisation may be required if the person is severely emaciated and has lost more than 25% of her body weight or when complications are encountered. Hospitalisation is also indicated where the response to outpatient therapy does not bring about change. Admission is also required if there are suicidal or other serious psychiatric complications. One must also look at the strength of the support system.
Individual psychotherapy should be the first choice of treatment. A dietician is extremely important in offering adjunct treatment.
If the person is still living at home, family therapy will probably be suggested. Group therapy with a supportive network of people experiencing similar problems is best as an adjunct therapy, but a good option where finances are very limited.
Nutritional advice and medical attention will support these forms of psychotherapy. A target diet will be established in conjunction with the patient, who will be slowly coached to eat the required amount of calories for a healthy diet. A system of rewards for positive eating behaviour may be established, but one must be careful about rewarding compliances. Affirmation and encouragement is best. Rewards can lead to relapses as there is sometimes a perceived lack of motive when goal weight range is achieved. Antidepressant and anti-anxiety drugs have been found to be useful in some cases.
There is no known method for the prevention for anorexia, but the risk of a person developing the disorder may be reduced in the following ways:
- Parents and caregivers can help children focus on their strengths and reinforce a positive self-image in their child.
- Parents can take care that a child’s sense of self worth does not become too closely related to feelings about body image and weight.
- Parents should not criticise children for being overweight or place undue emphasis on weight.
- Parents should discourage their children from dieting and rather focus on healthy eating patterns.
- People should try to spot suspicious behaviour or rigorous dieting as quickly as possible.
- Ideally, there should be less media emphasis on false ideals of ultra-thin body weight.
Reviewed by Graham Alexander Clinical Psychologist, M.A. (Clin.Psych.) UCT, 16 March 2007