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Eating Disorder

Anorexia Nervosa


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Anorexia nervosa is a type of eating disorder.

The essential features of anorexia nervosa are:

  1. Refusal to maintain minimally normal body weight consistent with one’s age and height.
  2. Intense fear of gaining weight or becoming fat.
  3. Disturbance in the perception of one’s body shape and size.
  4. In the case of a menstruating female, the absence of at least three consecutive menstrual cycles.

There are two subtypes of anorexia nervosa. They are:

  1. Anorexia nervosa, restricting type which is characterized by using dieting, fasting or excessive exercise to lose weight.
  2. Anorexia nervosa, binge-eating/purging type which is characterized by regular binge eating or purging or both. The purging is achieved through self-induced vomiting or the misuse of diuretics (chemicals which induce excessive urination), laxatives or enemas. Most people who binge eat also tend to purge. However, some who purge may not binge eat.

The typical profile of an individual with anorexia nervosa

Studies show that about 1 to 2 % of adolescents and young women suffer from anorexia nervosa. Although anorexia nervosa usually begins after puberty in the mid teens, females as young as 10 years can suffer from it.  Anorexia nervosa is rare in males. The female to male ratio for the disorder is about 15 to 1.

The teenager girl with anorexia nervosa tends to be a quiet, compliant, hard working and unassuming individual whose adolescence has been smooth before the onset of the disorder. She appears to be close to her parents but is quite unable to confide in them and deal with emotional and psychological issues which trouble her.

She may be normal or a touch over in her weight. She starts to diet in response to teasing by her peers or education about healthy diet. In other instances, she may have lost her appetite as a result of a physical illness, or she is under stress due to a personal crisis or family problem.

Initially, her dieting consists of avoiding high fat and high caloric food. Later, she avoids even the normal healthy diet. She avoids eating with the family so that they would not notice her eating habit. She may use excuses like she is not hungry or she has just eaten before her normal mealtime. During other occasions, she may throw food away and pretend that she has eaten it.

When she feels that the dieting is not working, she may resort to self-induced vomiting or purging. Typically, she excuses herself to go to the bathroom after eating. Initially, she has to stick her finger into her throat to induce vomiting. Later, she may be able to vomit on demand. She may use laxatives to prevent her body from absorbing the calories or diuretics to get rid of fluid in order to achieve a lower weight.

Her exercise regime is excessive and rigid, consisting of hundreds of sit up a day, jogging and skipping. She feels compelled to exercise as soon as she has eaten some food so that the calories are not absorbed. She feels guilty when she does not exercise.

As she loses weight, her ideal target body weight keeps dropping as well so that she is never happy with her thinness. She complains that she is still fat and her stomach is sticking out. She keeps on dieting and losing more and more weight. To hide her thinness, she wears loose and big clothes. She wears multiple layers and long sleeves even on a very warm day. She becomes pedantic with food. She insists on shopping for food and cooking for the family. She takes over the kitchen and prepares elaborate meals that she insists other should eat.

After a while, she stops having her menstrual period. She is, however, unconcerned. Her health continues to deteriorate. She may develop a depression. Her social life is limited because she avoids going to parties where she has to eat. Her school or college grades continue to slide because of her preoccupation with food and problems with concentration and short-term memory.

She does not seek help voluntarily. Her parents force her to see a doctor when they accidentally discover how thin she is, or she has developed other health problems or a psychiatric illness such as a depression. By this time, the school or college would have noticed that she is struggling with her study.

The physical complications of anorexia nervosa

Anorexia nervosa can result in many physical complications. Some of these may be life threatening.

  • Low blood pressure which can cause dizziness and fainting spells.
  • Underactive thyroid gland.
  • Lethargy and cool intolerance.
  • Dry skin.
  • Brittle hair and nails.
  • Joint swelling.
  • Constipation.
  • Menstrual problems.
  • Bleeding problem due to fragile blood vessels.
  • Electrolyte imbalance due to vomiting or misuse of diuretics. Severe electrolyte imbalance can cause abnormal heart rhythm, leading to death.
  • Erosion of the dental enamel by gastric acid as a result of vomiting.
  • Tearing and bleeding of the stomach and esophagus (the tube that connects the throat to the stomach) due to self-induced vomiting.
  • Osteoporosis due to the lack of calcium.
  • Anaemia due to iron deficiency.

Psychiatric conditions associated with anorexia nervosa

  1. People with anorexia nervosa are usually depressed. They become socially withdrawn, irritable, tired and lose their interest in the usual pleasurable activities. They may suffer from insomnia, feeling of hopelessness, concentration difficulty and short-term memory problem.
  2. Obsessive-compulsive problems that are either related or not related to food are common among those with anorexia nervosa. For example, some may compulsively collect recipes or hoard food. Others may develop obsessive-compulsive disorders relating to cleaning, counting or checking.
  3. Overall, about 10% of anorexia nervosa sufferers die from suicide.

The causes of anorexia nervosa

The causes of anorexia nervosa are unclear. However, there are certain factors that are associated with a higher risk of developing the disorder. These are:

Personal factors. People with anorexia nervosa tend to be individuals who are strong-willed and disciplined with a strong need to control. They are tenacious and do not give up easily. The more they perceive that things around them are becoming disorderly, they more they want to exert their control. Puberty, body changes, family stresses and other vicissitudes of life are threatening to these individuals. Consequently, they exert their control by a tight regulation over their food intake and their body weight.

Family factors. People with anorexia nervosa may come from families with intrusive and over controlling parents. Their family culture is one that does not encourage open expression and exploration of feelings. The individual develops anorexia nervosa as a way to combat the parents’ intrusiveness and control.

Social factors. Anorexia nervosa is common in industrialized societies where thinness is extolled. It is common among those who pursue the professions of modeling, acting, dancing and gymnastic where thinness is a symbol of beauty and success.

Treatments of anorexia nervosa

Treatments should be multimodal and focus on a number of areas.

Weight gain to an acceptable level. This can be achieved through sound nutritional advice and proper diet. Once the person has put on the weight, the depressed mood, obsession with food and other negative personality traits also improve.

Family therapy. This is particularly important as the whole family is usually affected by the anorexia nervosa. Initially, the family needs to be educated about the illness. Later, the issues of boundary, control and autonomy can be addressed. Family therapy should also focus on helping the person to maintain the gains made through treatment.

Individual therapy. This is important because the issues of identity, self-esteem, self-worth and self-image can be addressed through this forum. Most people do not benefit much from deep individual therapy until their weights are restored to a more normal level.

Medication. Medication is not very helpful in the treatment of anorexia nervosa. However, medication may be useful if other psychiatric illnesses such as depression and obsessive-compulsive disorders are present.

Stress management. This is particularly helpful once the person has recovered from the anorexia nervosa. Learning to deal with stress will help to reduce the chance of future relapse.

The outcome of people with anorexia nervosa

The short-term outcome is good as up to 90% of the sufferers gain weight. However, the result after five years is not so encouraging. Only 50% of the sufferers continue to maintain their gains whilst the other 50% continue to struggle with their poor eating behaviour and weight loss. Generally, those sufferers who are older than 18 years, lose excessive weight before seeking help, resort to vomiting and purging to lose weight and have severe family problems tend to have a much poorer outcome.

So, the important thing to remember about anorexia nervosa is this:

Anorexia nervosa is not simply a poor eating habit; it is a very serious illness!  

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