Anorexia Nervosa

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Anorexia Nervosa

Anorexia (an-o-REK-see-uh) nervosa often referred to as anorexia is an eating disorder that is distinguished by an abnormally low body weight. Anorexia is a far less common in males than in females, with the general clinical population reflecting approximately a 10:1 female-to-male ratio. 0.9% of American women suffer from anorexia in their lifetime. Anorexia can affect people of all ages, genders, sexual orientations, races, and ethnicities. Although the disorder most frequently begins during adolescence, an increasing number of children and older adults are also being diagnosed with anorexia. Just because a person is not immensely underweight or a person is not visibly emaciated, does not mean they do not suffer from anorexia. Studies have found that larger-bodied individuals can also have anorexia, although they may be less likely to be diagnosed due to cultural prejudice against fat and obesity.

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Anorexia Nervosa Defined

Anorexia (an-o-REK-see-uh) nervosa is an eating disorder that is distinguished by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of weight. People with anorexia spend a large part of their life doing what they can to control their right and go through extremes to keep their weight low. Their focus on their weight is so severe that it interferes with their life and is dangerous to their physical health. Anorexia is not about food, but related to an inability to handle extreme emotional problems in a healthy manner.

Different Types of Anorexia Nervosa:

There are two subtypes of anorexia nervosa: restricting type and binge-eating/ purging type.

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

Binge-eating/ purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Anorexia Nervosa Causes:

Anorexia nervosa common begins during adolescence or young adulthood. It is rare that it begins before puberty or after the age 40. The onset of this disorder is often associated with a stressful life event, like leaving home for college. There may be a genetic component to those are at higher risk of developing anorexia. It is still not clear which genes are involved. People that have a genetic tendency toward perseverance, perfectionism, and sensitivity are all traits associated with anorexia. Other people with anorexia may have obsessive-compulsive personality traits, which contribute to their ability to stick to strict diets. High levels of anxiety play a role in their ability to engage in restrictive eating. Finally, in the modern Western world there is an emphasis and pressure on being thin. Being thin is attributed to being successful and beautiful, and striving toward this goal may play a role.

Anorexia Nervosa Symptoms:

To be diagnosed with anorexia nervosa, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met:

  1. There is a restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is considered weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
  2. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
  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 persistent lack of recognition the seriousness of the current low body weight.

There are several physical symptoms related to anorexia nervosa. They may include:

  • Extreme weight loss or not making expected developmental weight gains
  • Insomnia
  • Fatigue
  • Low blood pressure
  • Dehydration
  • Thin appearance
  • Swelling of the arms or legs
  • Abnormal blood counts
  • Intolerance of cold
  • Absence of menstruation
  • Dizziness or fainting
  • Dry or yellowish skin
  • Bluish discoloration of the fingers
  • Constipation and abdominal pain
  • Irregular heart rhythms
  • Hair that thins, breaks or falls out
  • Soft, downy hair covering the body, also known as lanugo 
  • Eroded teeth and calluses on the knuckles from induced vomiting

Suicide risk is elevated in anorexia nervosa, with rates reported as 12 per 100,000 per year. It is important that when assessing for anorexia that a suicide risk assessment is also completed. Primary care physicians (pediatricians and family physicians) may be in a good position to identify early indicators of anorexia and prevent the development of full-blown illness.

How to Approach a Loved One:

There is not a perfect way to approach a loved one that you assume or know is struggling with anorexia. Since the desire to remain thin is their biggest concern, even over their health, your loved one may not be interested in seeking help, no matter what you say. If you notice that a family member or friend has severe dieting habits and dissatisfaction with appearance, low self-esteem, consider talking to him or her about these issues. Urge them to talk to their doctor. Even though you may not be able to prevent your loved one from developing anorexia, you can still talk about healthier behavior or treatment options. It is important that you reassure your loved one that they will not be alone and you will support them in getting the help they need. For more information on how to approach a loved one visit: http://www.anad.org/education-and-awareness/about-eating-disorders/how-to-help-a-loved-one/

Types of Anorexia Nervosa Treatment:

It is possible that people with anorexia can recover, but they have an increased risk of relapse during periods of high stress or during triggering situations. It is important to have ongoing therapy or periodic appointments during times of stress as well as nutrition education for continued recovery. Treating anorexia is generally done with a team approach due to the physical aspects that impact the body. The team usually includes dietitians, mental health professional and doctors.

Hospitalization and other programs

If a person’s life is in immediate danger, the first step to treatment must be in a hospital emergency room. The hospital setting address issues such as a heart rhythm disturbance, dehydration, electrolyte imbalances or a psychiatric emergency. Hospitalization may be required for severe malnutrition or continued refusal to eat, medical complications, or severe psychiatric problems. If you choose to go to a clinic it is imperative that the clinic specializes in treating eating disorders. Specialized eating disorder programs may offer more-intensive treatment over longer periods of time. Day programs and residential programs are also an option besides full hospitalization, but safety is most important.

Restoring a healthy weight

The initial goal of treatment is getting back to a healthy weight. A healthy weight and proper nutrition is necessary to continue with the rest of treatment as well as for safety reasons. This part of treatment involves a team like your dietician, primary care doctor, a psychologist or other mental health professional. A dietitian will offer directions meal planning, healthy eating and calorie requirement to reach appropriate weight and maintain it. The primary care doctor will also supervise calorie intake and weight gain, as well as any other medical needs. Finally, a psychologist or other mental health professional can help develop behavioral strategies or plan to monitor and maintain a healthy weight. Family, will likely be involved in helping you maintain normal eating habits because they are also part of your support system.

Medical care

Medical care is crucial in treating anorexia because this disorder can be accompanied with a constant need to monitor vital signs, electrolytes, hydration level, and other physical conditions. For people that are refusing to eat and their body mass is extremely low to the point of safety, they may initially require feeding through a tube that's placed in their nose and goes to the stomach (nasogastric tube). Medical care is coordinated by a primary care doctor, mental health professional and or with other professionals involved.

Family-based therapy

This is the only evidence-based treatment for teenagers with anorexia. Teenagers with anorexia are unable to make good choices about eating and health while suffering from anorexia. This type of therapy prepares their parents to help their child with re-feeding and weight restoration until their child can make good choices about health. This is referred to as the “Maudsley Method.” Family therapy is also helpful because it gives the opportunity for the family to understand and realize the roles they are playing in supporting the disordered eating, and suggest ways the family can help the person with anorexia acknowledge the problem and seek out treatment.

Individual therapy

Psychotherapy is the most common treatment for anorexia and has the greatest research support. One goal of psychotherapy is to normalize eating patterns and behaviors to support weight gain. Cognitive behavioral therapy, specifically enhanced cognitive behavioral therapy, has been shown to help. Cognitive-behavioral therapy will often focus on identifying and altering dysfunctional thought patterns, attitudes and beliefs, which may trigger and perpetuate the person’s restrictive eating. Another goal is to help change distorted beliefs and thoughts that maintain restrictive eating. Individual therapy can be very helpful in addressing not only your disordered eating, but also your overall emotional health and happiness. The purpose is to address the underlying cognitive and emotional issues that result in anorexia.

Medications

There are no medications that are approved to treat anorexia.

 

Differences Between Common Disorders:

There are other possible causes of either significantly low body weight or significant weight loss that should be considered when differentiating between anorexia nervosa, especially when the presenting features are atypical (e.g., onset after the age of 40).

  • Medical conditions (e.g., hyperthyroidism, occult malignancies, gastrointestinal disease, and acquired immunodeficiency syndrome (AIDS)- Serious weight loss may occur in medical conditions like these, but there is no disturbance in how individuals view their body or their weight. There is also no fear in gaining weight or persistent behaviors that interfere with gaining weight.
  • Bulimia nervosa- Unlike individuals with anorexia nervosa, binge-eating.purging type, individuals with bulimia nervosa maintain body weight at or above a minimally normal level.
  • Avoidant/restrictive food intake disorder- Individuals that struggle with avoidant. restrictive food intake disorder may struggle with weight loss or nutritional deficiency, but do not have a fear of gaining weight, becoming fat, nor a disturbance in how they view themselves.
  • Substance use disorder- Due to poor nutritional diet for individuals with substance abuse disorders, there may be a loss of weight, but there is not a disturbance of body image or fear of gaining weight.  If it is noted that a person that struggles with a substance use disorder and is reducing their appetite as well as a fear of gaining weight, there may be a possibility of comorbid anorexia nervosa and substance abuse disorder.
  • Major depressive disorder- Severe weight loss may occur in individuals that struggle with major depressive disorder because of a lack of appetite, but they do not have either a desire for excessive weight loss or an intense fear of gaining weight.
  • Social anxiety disorder (social phobia), obsessive-compulsive disorder, and body dysmorphic disorder- There are overlapping features for anorexia, social phobia, OCD, and body dysmorphic disorder. Being embarrassed to eat in public or being seen eaten in public is a symptoms of social phobia. Exhibiting obsessions and compulsions related to food is related to OCD and being preoccupied with an imagined defect in bodily appearance, as in body dysmorphic disorder. These symptoms are not the same as having fear of gaining weight and engaging in behaviors to stop from gaining weight.

Resources:

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. (5th ed.) Arlington, VA: American Psychiatric Association.

Grohol, J. (2018). Treatment for Anorexia. Psych Central. Retrieved at: https://psychcentral.com/lib/treatment-for-anorexia/

Mayoclinic.org. (2018). Anorexia nervosa, Diagnosis and treatment. Mayo Clinic. Retrieved at: https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/diagnosis-treatment/drc-20353597

National Association of Anorexia Nervosa and Associated Disorders. (2018). Retrieved at: http://www.anad.org/education-and-awareness/about-eating-disorders/eating-disorders-statistics/

National Eating Disorders Association. (2018). Anorexia Nervosa. Retrieved from: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia

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