213 Anorexia Nervosa (307.1)
DSM-IV-TR criteria
A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body shape on self-evaluation, or denial of the seriousness of the current low body weight.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration).
Specify type:
- Restricting Type: The person describes presentations in which weight loss is accomplished by dieting, fasting, or excessive exercise and has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas).
- Binge-Eating/Purging Type: During the current 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).(The binge-eating/purging type used to be called bulimiarexia. That term is now archaic.). Some in this subtype do not binge, but do purge after consuming small amounts of food.
Associated features
People that suffer from Anorexia Nervosa typically view themselves as overweight. The term anorexia means “loss of appetite”; however, individuals that have anorexia constantly feel hungry since they constantly deprive their body of adequate nutrition. Often time’s individuals with anorexia refuse to eat in order to lose weight. If they feel they have gained weight, they may use extreme measurements to become thin, such as using laxatives, induce vomiting, excessive exercise, consuming diet or diuretic pills, and obsessing all caloric intake of everything they eat.
Some anorexic women consider amenorrhea as a milestone in weight loss; if they are menstruating they often think they are too fat.
Many people that have anorexia often deny how severely underweight they are; they think they are still too fat and need to continuously lose weight. In young girls, obsession with weight typically begins at the onset of puberty. Girls who mature early are at a greater risk of developing an eating disorder than girls that mature at a normal rate. Other people are worried about their health but not in such an extensive way as anorexic people. However, anorexic individuals rarely believe that their current weight is acceptable and do not seem to find a point at which it is unhealthy to lose additional weight. Therefore, they end up losing more weight than necessary which can cause serious health problems.
The signs and symptoms of anorexia can include: low body temperature, coldness in the extremities, and constipation for some time. The individuals with anorexia nervosa are unable to tolerate cold temperatures; they also often report fatigue or tiredness, episodes of dizziness, constipation, periodic vomiting, and shortness of breath. Individuals also tend to develop irregular menstrual cycles or actually lose their periods for long stages of time due to malnutrition and being underweight. Anorexia can also affect a woman’s fertility. In females, there are low levels of serum estrogen, and there are low levels of serum testosterone in men. Thinning of the hair, sunken eyes like low in eyelids, and puffy cheeks are some of the most observable signs that one may be anorexic. The individuals, however, are unable to tell that these characteristics are seen as abnormal towards others. Anorexia nervosa is commonly co-morbid with mood disorders. Many individuals with the eating disorder also report anxiety disorders such as obsessive-compulsive disorder (OCD) and social phobia disorders. People who suffer from anorexia also tend to have a harder time with concentration due to the fact that they are constantly reminded by their body of its nutritional needs.
The behaviors expressed tend to be more introverted like social withdrawal in particular situations and decreased interest in sex over time. An individual who views themselves as excessively thin may feel sexually undesirable resulting in a reduction of sexual interest. Recovery rates are low for anorexia nervosa. Although 50% achieve partial recovery, only 10% fully recover from the disorder. Within the first five years of the diagnosis, many individuals with the restricting subtype of anorexia nervosa will develop an eating pattern that is more typical of the binge-eating/purging subtypes. If unchecked, chronic starvation and weight loss can result in severe dehydration and electrolyte imbalance that may require hospitalization if not cared for or attended to soon.
These individuals put extreme amounts of emphasis on their weight that they may actually measure everything that comes in and out by the ounce.
Child vs. adult presentation
Anorexia nervosa normally begins in mid to late adolescence (age 14-18 years). It is not likely to see children under the age of 13 with anorexia because of their lack of concern with social acceptance and appearance. Seventeen is the average age of onset of anorexia nervosa. Rare cases of older adults being diagnosed with the disorder do exist, however, it is highly unlikely that an individual over 40 years of age will be diagnosed. Most individuals in the age group of 14-18 are very social, seek relationships and social acceptance much of the time. These individuals may become very self-conscious about their physical appearance, predisposing them to the development of anorexia nervosa.
Gender and cultural differences in presentation
Anorexia nervosa is more common in females than in males. This may be the result females being more concerned about their appearance than males. It is a common stereotype that many females are more willing to go to extremes to look better. Among the amount of people with the disorder, about 95% are female compared to 5% of whom are male. Most of these come from high-achieving families and believe they have to be presentable, which is viewed as thin and beautiful opposed to big and bulky. There has also been an associated link found between Anorexia and authoritarian parenting styles, many say the child can feel too much pressure from their parents, and thus develop disorders such as anorexia. Anorexia nervosa is most prevalent 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, but currently there has been an increase in the number of African American females who are being diagnosed with this disorder. Anorexia is also more common in middle and upper socioeconomic groups. According to the U.S. National Institute of Mental Health (NIMH), an estimated 0.5% to 3.7% of women will suffer from this disorder at some point in their lives.Approximately half of anorexic females are predicted to develop bulimia, which is also considered a psychological eating disorder, and is defined as excessively overeating and then different improper methods are used to get rid of the food just ingested, such as throwing up.
Epidemiology
In women, anorexia nervosa can occur between a percentage rate of 0.5% to 3%. The lifetime prevalence rate of this disorder is around 0.5%. Approximately 1% of the population will be diagnosed with anorexia nervosa in a lifetime, and there is some concern that this rate is increasing. Since the 1930s, there has been an increasing number of anorexia nervosa cases. This may be due to the increase in the prevalence of industrialized societies, as well as the constant pressure to be thin as implicated by the mass media (characteristics of personality and the cultural approval of thinness). Television shows constantly portray favorable bias toward thin, better looking people as opposed to those who are considered to be overweight individuals.
Anorexia Nervosa usually begins in mid to late adolescence. The rarely occurs in females over 40 years of age. The onset may be associated with a strssful life event. The course and outcome are highly variable. Some never fully recover after a single episode; some exhibit a pattern of weight gain and loss, and others experience a chronic course over many years. With time, a significant of the Restricting Type develop binge eating, changing to the Binge Eating/Purging Subtype. The long term mortality is over 10%, most commonly from starvation, suicide, or electrolyte imbalance.
Etiology
Socio-cultural factors: Industrialized societies place great value on women who are thin. Evidence of this can be seen in the entertainment industry, (such as movies, TV shows, advertising and catalogs), where nearly all of the women featured are thin. Being thin is considered better than being bigger. Through this media, young women are conditioned to believe that only “thin” is beautiful, and they may become obsessed with attaining this image, such as an hour glass figure (big in the hips and thin in the waist). Inner beauty is not a factor in the real-world which helps one achieve success; it is physical appearance and social capital. Furthermore, being thin in these industrialized societies is culturally reinforced by what the favorable definitions are for popularity. Since men are also conditioned to believe that “thin” is beautiful, the attention that petite women receive from the opposite sex acts to reinforce women’s attitudes that they look good being thin and that is the body image men desire. Anorexia Nervosa is far more prevalent in industrial societies such as the United States, Canada, Europe, Australia, Japan, New Zealand, and South Africa. Moreover, eating disorders are less prevalent in societies where women have fewer decision-making responsibilities.
Psychological Factors: Individuals with anorexia nervosa tend to be perfectionists, a person who places very high standards on everything and is displeased with things if they fall short of the expected standard, which affects the way they look at their body. They become so obsessed with achieving the image of the “ideal woman” that they will push themselves to dangerous extremes and begin possessing obsessive or narcissistic qualities. They also engage in compulsive behavior, which includes frequently checking their appearance and weight, like combing their hair, shaving, brushing teeth, or even repetitive flossing. These individuals crave control, especially over their eating habits, by engaging in restrictive diets and always eating the same thing because nothing else is satisfying. They in return learn to ignore the resulting internal cues of hunger. Psychological symptoms of anorexia consist of those characteristics that are related to the development of the disorder and those that are secondary to the disorder.
Biological factors: Twin studies in anorexia have found concordance rates for mono-zygotic (identical) twins to be significantly higher than concordance rates for dy-zygotic (nonidentical or fraternal) twins. This finding suggests that there may be genetic factors involved in predisposing individuals to anorexia nervosa, such as gene combination with parental sequences, passed down. There is also an increased risk of anorexia nervosa developing in the first-degree biological relatives of anorexic individuals. They have a greater chance of acquiring the odd sequences that cause these problems in anatomy and dietary functions. There also can be a weak genetic component more developmental than mental so other factors should be considered like family history of eating, perfectionist and their personality.
Empirically supported treatments
Anorexia nervosa is difficult to treat and relapse is common among the patients with the disorder. Most anorexic individuals do not see a problem with themselves and, consequently, are not admitted to treatment by their own accord. Often, a friend of the troubled individual has to intervene and recommend that he or she seek help to further their daily functioning. Help may be gained either through medication or behavioral therapies. Denial, coupled with an individual’s unwillingness to participate in treatment, can make changing a patient’s attitude very challenging.
There are two major goals for treating patients with this disorder:
- Getting the patient to gain weight is not an easy task. It is important that the patient gradually begins to eat more during each meal time and not forcibly trying to eat larger amounts of food at one time. If adequate nutrients are not obtained in food, normal functioning is inhibited. It is crucial for underweight individuals to gain more weight, at least to the point where health and nutritional concerns are no longer a factor. Underweight individuals possess less ability to fight off pathogenic diseases because their immune systems are not prepared to provide proper circulation to crucial areas of the muscles, glands, and other areas due to a lack of nutrition. Also, the body needs the right amount of nutrition to be able to function to its normal capacity. However, the patient needs to be aware of the importance of gaining weight gradually because the body will encounter problems attempting to adjust to rapid increases in weight. If this occurs, it can cause complications in the individual’s digestive system and a person may become overstuffed and burst.
- Addressing other psychological, social, and environmental issues is a vital part of one’s treatment. During treatment, clinicians try to change the way the patient views his or her self. Clinicians goals are to address the issues that potentially caused the disorder, change the patient’s perspectives on body image, maintain a healthy diet, and help the patient classify a healthy weight. The clinicians let the patients know what is socially acceptable or popular and emphasize the vitality of maintaining healthy food choices. The clinicians also inform the patient of a respectable weight he or she should maintain.
When treating the young women and men who are suffering from anorexia nervosa, the most common technique is through family therapy. In family therapy, the clinician usually tries to change the patient’s attitude about their body image. They also try to increase the patient’s self-esteem by teaching him or her to accept the way his or her body looks and becoming satisfied with it. The family attends these counseling sessions with the patient and will gain control over the patient’s eating habits until the patient can maintain healthy habits oneself. They also reinforce what the clinician says. For example, the family members may stress that the patient’s body is fine and satisfying to the public eye. Families may also be asked to monitor exercise habits. If the patient exercises excessively, they will need to improve the workout by designating only a certain amount of time a day for exercise. However, this technique usually only lasts for a short period of time and the patient becomes bored with the activities. This is due to the fact that many patients are in denial and tend to get into a relapse or think that they are really fine, that everyone is jealous around them because they are better.
Another technique for treating people diagnosed with anorexia nervosa is attending self-help groups. The American Anorexia Bulimia Association is one organization that provides support groups for those who are suffering from eating disorders that need to talk it out with others experiencing the same problems. The more “experienced,” affected individuals with anorexia nervosa are very good when telling the “newbies” how to deal with certain problems they already have experienced. The same techniques do not work for everyone but can help ignorant patients that do not know where to turn for help. People can gather and give each other support to help them recover from this disorder and prevent them from going into denial or put in a relapse.
Medication is not recommended for treating people with anorexia nervosa. The main reason is because these individuals are often very thin. Because they are thin, their bodies have a harder time with the chemicals found in the drugs. Those with low body weight can overdose much quicker than others, and their immune system is very weak. They could become dependent on drugs such as Xanax or Valium, both are CNS depressants, which could cause a number of health, and maybe even legal problems that need to be avoided if at all possible. Psychotropic drugs can decrease the patient’s suffering, but also allow a degree of stabilization in the patient’s chaotic life. Some psychiatrists prefer to use SSRIs because of their efficacy. This could cause negative side effects and complications, sometimes even death. Estrogen may also be prescribed as part of treatment. Women with anorexia are at risk of fractures as a result of osteoporosis, which usually occurs during menopause; however, the lack of menstruation due to their low body weight puts them in a state like early menopause. There is some suggestion that taking estrogen can help some women have the ability to regain some of their bone functioning and stability that has been lost and prevent other fractures from possibly happening.
Parenting classes have been a new and upcoming technique that helps parents learn how to build self-esteem in their kids. This treatment helps the teen to value themselves as a person and learn to trust their abilities and feelings while working toward their goals.
- Individuals who suffer from Anorexia Nervosa believe that they are improving their appearance while often harming themselves by abstaining from food. See video https://youtu.be/8XVkPpDJfYE
https://youtu.be/8XVkPpDJfYE
- A girl discusses her life with Anorexia. Note: Some of the images in this video may be disturbing. See Video https://youtu.be/ZmzJt5G9ud8
- The following link is from Morning Edition on NPR. It is a short recount of a young girl’s experience with anorexia.
- The following link is from New and Notes on NPR. Farai Chideya interviews different people on eating disorders and anorexia specifically for African-Americans.
To view images of anorexia visit: Anorexia in Males and Anorexia in Females
Explanation of Anorexia Nervosa Impact of Eating Disorder
Story of 12yr old Bryony above: http://www.dailymail.co.uk/femail/article-432132/My-little-girl-anorexic-12.html