People with Anorexia Nervosa suffer an intense fear of gaining weight and refuse to stay at a healthy body weight for their age or height. Although many people at some point in their lives need to make an effort to lose weight to stay healthy and fit, when it becomes an unhealthy obsession, that is the realm of Anorexia Nervosa. These people focus intensely on their body fat and keep their weight far below the appropriate, healthy range. They view weight loss and gain as factors of diligence and self-control, and any gains haunt them until that weight is lost.
Individuals with anorexia will use different methods of losing weight in order to accomplish their goals, such as eating little or nothing, purging, excessive exercise, and use of laxatives, diuretics, diet pills, or other weight loss products. The most striking outward appearance of anorexia is the exceptionally low body weight and constant obsession over areas of body fat. Other easily visible physical signs include thinning hair, yellowing skin or eyes, growth of soft body hair, leg swelling, and general weakness. Additionally, people who purge by vomiting develop calluses on their hands, damaged teeth, and swollen cheeks. If the psychological component is not explored, Anorexia Nervosa can initially masquerade as a nutrition absorption disorder, food allergy, or even cancer due to the dramatically low weight.
Anorexia usually appears in adolescence and young adulthood. It rarely begins before puberty or after age 40. The beginning of the disorder is often associated with a stressful life event. Stress combined with a predisposition to poor self-esteem can lead people to associate negative feelings that they cannot control with weight, which they can control.
Causes and Risk Factors
Anorexia Nervosa appears in about 0.37% of women and is about 10 times more common in women than in men. This has contributed to a greater stigma surrounding the disorder in men, and, consequently, men tend to have a more severe stage of the disorder when they finally do seek help.
Over 50% of the risk of developing Anorexia Nervosa can be attributed to genetics. Having first degree family members with either Anorexia Nervosa or Bulimia Nervosa increases the risk of both disorders. Children of people with Anorexia Nervosa have ten times the average risk of developing the disorder as well.
A hectic and violent family life coupled with a lack of vocal support and approval from parents puts children at risk for developing Anorexia Nervosa. These kids tend to be exceptionally driven in areas of measured performance, such as school and sports. Sensation of control is a key piece to this puzzle. Blurred boundaries, lack of autonomy, and poor emotional support can lead adolescents to seek external validation through their appearance and to want control over what and how they eat. The disorder serves an emotional purpose in peoples’ lives, which is why so many of them are initially resistant to treatment.
Anorexia Nervosa most commonly appears in more industrialized cultures such as in North America and Europe. These cultures put a lot of emphasis on being thin and frequently treat it as a prerequisite for beauty. It is also more common in some sports such as body building, ballet, running, and gymnastics and in occupations like modeling and acting.
Depressive disorders are the most commonly co-occurring disorders, appearing in at least half of Anorexia Nervosa people. Early life trauma, such as physical or sexual abuse is also unfortunately common for these people. Obsessive-Compulsive Disorder frequently accompanies the restrictive type of Anorexia Nervosa, while Alcohol Use Disorder occurs alongside the Binge-eating/Purging subtype.
Diagnosing Anorexia Nervosa
Making the diagnosis
These people significantly limit the number of calories they take in on a daily basis. They are underweight as defined by a Body Mass Index (BMI) below the minimum of the normal range, which spans from 18.5 to 25. Despite being underweight, a powerful fear of gaining weight chronically plagues these people. They consistently restrict their eating even in the face of medical problems from their low weight. Patients with anorexia steadfastly deny that their low weight is a problem. They are grossly unsatisfied with their physical appearance and constantly obsess over losing more weight.
The two major subdivisions of Anorexia Nervosa are the Restricting type and the Binge-eating/purging type. People with the Restrictive type lose weight either through decreased food intake or over-exercising. The Binge-eating/Purging type is characterized by episodes of significant eating followed by vomiting and use of laxatives. This can be confused with Bulimia, but the key difference is that patients with Anorexia, Binge-eating/Purging type, are underweight while those with Bulimia have normal or above normal weight.
People with anorexia often have some symptoms similar to depression because of their reduced food intake. They can have low energy, depressed mood, sleep disturbances, and seclude themselves from friends and family. In addition, these people frequently have symptoms of obsessive compulsive behavior such as constant mirror checking, weighing themselves repeatedly, measuring body parts for “fat”, and measuring food or calories consumed daily. They also may obsess over food and cooking despite under eating.
Chronic calorie deficits and malnutrition take a major toll on the body. Blood tests reveal multiple vitamin deficiencies and low blood cell counts, while bone scans show low bone density. Abnormal electrolyte levels in the blood will lead to heart rhythm disturbances, low heart rate, and low blood pressure. Hormone levels are disturbed as well. Men have low testosterone, and women have low estrogen, which leads to irregular or absent menstrual periods. People also have a lower body temperature and are more susceptible to the cold. Younger patients who are still maturing will have slowed growth and delayed onset of puberty.
Body Mass Index plays a big role in determining the severity of the disorder, and values farther below the normal range imply a worse condition. Additional symptoms such as the negative physical and mental health effects of low weight also contribute.
Treating Anorexia Nervosa
Restoring healthy weight safely
Hospitalization is necessary when any of several symptoms from chronic malnutrition are present. These include weight under 75% of ideal body weight, dehydration, abnormal heart rhythms, electrolyte imbalances, low heart rate, low blood pressure, slowed growth in kids, complete abstinence from eating, out of control behavior, and medical or psychiatric emergencies.
Not only can these effects of anorexia require hospitalization, but also the process of returning to a healthy weight needs careful medical supervision. Refeeding syndrome is a derangement of the body’s electrolyte balances that results from unrestricted eating following chronic malnutrition like that in anorexia. Risks include potentially fatal heart rhythm disturbances, widespread organ damage, breathing problems, and neurological issues. Anyone who has been underfed for even as little as five days is in peril, and hospitalization may be necessary for close monitoring. Hospitalization is most effective and its results last longer when people remain in the hospital until their weight is at least 90% of what is appropriate for their age and height.
For people who do not need to be in the hospital but still need extra help, these services can also come in the form of a day hospital, where they spend several hours a day, five days a week in treatment but go home at night. For some people this treatment structure is just as effective as hospitalization but gives people more independence. Day hospitals can also serve as a stepping stone to ensure that progress made while staying in the hospital is not lost when people return home.
Recovery team effort
Those who are not so sick that they have to be hospitalized still need a comprehensive treatment team that includes, at the very least, a psychiatrist, a therapist, and a dietitian. Regular meetings with the patients enables dietitians to monitor their physical recovery and quantity and the quality of their nutrition. Dietitians also help address eating behaviors and attitudes surrounding food.
The two most commonly used forms of therapy are a family-based program called the Maudsley Approach and a customized form of Cognitive Behavioral Therapy. The Maudsley Approach is specifically designed for treating adolescent patients. The treatment begins by recruiting and training parents to help monitor and constructively encourage the child’s eating until the child begins to eat more voluntarily. The child slowly regains more autonomy over eating by demonstrating a willingness to maintain a healthy weight. Once the child is close to their ideal body weight, the treatment focus shifts to work on the underlying issues of personal identity related to the disorder.
Enhanced Cognitive Behavioral Therapy (CBT-E) is specifically designed to treat eating disorders in both adolescents and adults. CBT-E helps people identify their distorted views of their own bodies. These people feel a tremendous desire to have absolute control over their body image, and this leads to the severely restrictive eating patterns of Anorexia Nervosa. CBT-E begins by enhancing the peoples’ investment in treatment, planting the seed of desire to change and get better. It helps them build a normalized eating schedule and address the rigid rules around eating that are characteristic of the disorder. Therapy also addresses low self esteem, perfectionism, and the compulsive behaviors around body image such as repeated weighing and time spent looking in the mirror.
There are no medications that directly promote recovery from anorexia. The antidepressant, Prozac (fluoxetine), is helpful in supporting people who have already regained at least 85% of their ideal body weight. Antidepressants are also helpful for treating the frequently co-occurring depressive disorders and obsessive-compulsive disorders and in reducing binge eating and purging behaviors. The antipsychotic, Zyprexa (olanzapine), can help reduce eating-related anxiety and obsessions and promote participation in recovery.
Managing Anorexia Nervosa
Acknowledging the issue
Anorexia Nervosa is notoriously difficult to treat because of the denial that is inherent to the disorder. People with this disorder have a fundamentally distorted view of their body. They believe deeply that they are overweight despite evidence to the contrary. Unfortunately, people who don’t believe they are sick are less likely to commit to treatment. Less than half of people with Anorexia Nervosa make a full recovery, and 20% make little or no improvements, suffering most of their lives. People usually end up coming to medical attention either because they are brought by concerned friends or family or because of the medical issues that arise due to their malnutrition.
When the patient is under 18, the resistance to treatment is a bit easier to overcome as long as parents are steadfast in their insistence on the child engaging in treatment. Friends and family of affected adults have much less control over the situation. The best strategy in those cases is to give consistent, honest, and gentle encouragement to seek treatment.
Additional medical support
The lasting physical effects of Anorexia Nervosa require medical management. Decreased bone density is a common consequence, and people should consider taking supplemental calcium and vitamin D. Physicians may also prescribe estrogen in the form of oral contraceptives and bisphosphonate medication to help restore bone health. People who binge and purge need to have regular dental care to address the damage to teeth that results from repeated vomiting.
Anorexia Nervosa is one of the most deadly psychiatric disorders and is more lethal than any other eating disorder. About half the deaths are due to suicide, and the rest result from the multitude of possible medical complications. In an average 10 year period, 20% of untreated people and 5.6% of all people with Anorexia Nervosa will die of the disease.