Anorexia Nervosa

1. Anorexia Nervosa Andrea Toro Elizabeth Sherwood

2. Introduction • Eating Disorders • are characterized by severe disturbances in eating behavior (American Psychiatric Association, 1994, 539). • Anorexia Nervosa • Anorexia Nervosa often begins as an ordinary attempt at dieting to lose a few pounds (Sondon-Hagopian, 1992, 71). With the passage of time, however, the individual may obsess about his or her weight and appearance claiming he or she is still too fat in spite of contradictory evidence. • DSM IV describes Anorexia Nervosa as the refusal of an individual to maintain a minimally normal body weight, an intense fear of gaining weight, and a disturbance in the perception of the shape or size of his or her body (American Psychiatric Association, 1994, 539).

3. General Overview • Two Types of Anorexia • The restricting type is characterized by weight loss due to food restriction (Davison and Neale, 1997, 208). • The binge-eating-purging type occurs when an individual is engaged in binge eating and purging (Davison and Neale, 1997, 208). • Many women have symptoms that resemble those of Anorexia Nervosa, but the symptoms are not severe enough to constitute a diagnosis for the disorder (Long, P.W., 1995). According to one study, two-thirds of college women have an eating binge at least once a year, forty percent at least once a month, and twenty percent a least once a week.

4. Prevalence • This disorder affects one to five percent of the population (American Psychiatric Association, 1994, 543). • psychosociological disease which affects young and healthy girls primarily in adolescence (Sondon-Hagopian, N., 1992, 71). • Gender related: Ninety percent of those who suffer from Anorexia Nervosa are women; it usually begins in adolescence but may appear as early as nine years of age (Long, P.W., 1995). • Age differences: Women of all ages rated their current figure as significantly larger than their ideal figure; however, young women’s ideals were congruent with their perceptions of male preferences while older women seem to aim for an ideal that is significantly larger than what they think men find attractive (Stevens &Tiggemann, 1998).

5. Historical Background • First Descriptions • Eramus Darwin in 1796 stated, “Some young ladies I have observed to fall into this general disability (can) just be able to walk about. I have sometimes ascribed this to their voluntary fasting when they believed themselves too plump…” (Gordon, A.G., 1997, 1041). • William Gull in 1869 first described the disorder as a persistent lack of appetite and refusal of food resulting from emotional conflict (Goldenson, R.M., 1970, 83). The term anorexia refers to loss of appetite, and nervosa indicates for emotional reasons (Davison and Neale, 1997, 207).

6. In recent years... • Eating disorders and Anorexia Nervosa first appeared in DSM for the first time in 1980 as one subcategory of disorders beginning in childhood and adolescence (Davison & Neale, 1997, 207). • DSM-IV recognized eating disorders as a distinct category reflecting the increased attention they have received recently (Davison & Neale, 1997, 207). • There has been an dramatic increase in both the scientific literature and the popular press about eating disorders (Furnham & Manning, 1997, 389). However, diet advertisements and articles appear ten times more frequently in women’s than men’s magazines (Cusumano & Thompson, 1997). • Over the last twenty years, a higher portion of women in their late teens and early twenties have been hospitalized for Anorexia Nervosa (Long, 1995)

7. Diagnosis • Diagnostic Criteria of Anorexia Nervosa • Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 85 percent below that expected; or failure to make expected weight gain during period of growth, leading to body weight 85 percent below that expected (American Psychiatric Association, 1994, 544). • Intense fear of gaining weight or becoming fat, even though underweight ( American Psychiatric Association, 1994, 544). • 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 denial of the seriousness of the current low body weight (American Psychiatric Association, 1994, 545).

8. More DSM Criteria • In postmenarcheal females, 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.) (American Psychiatric Association, 1994, 545). • Associated features • Some people with this disorder cannot exert continuous control over their intended voluntary restriction of food intake and have bulimic episodes,often followed by vomiting ( American Psychiatric Association, 1987). • Other peculiar behaviors concerning food are common. They may be prepare elaborate meals for others. ( American Psychiatric Association, 1987).

9. DSM (Cont’d) • Also, compulsive behavior, such as hand-washing maybe present during the illness and may justify the additional diagnosis of Obsessive Compulsive disorder (American Psychiatric Association, 1987). • Many of the adolescents have delayed psychosexual development and adults have a markedly decreased interest in sex (American Psychiatric Association, 1987). • When seriously underweight, many individuals with Anorexia Nervosa manifest depressive symptoms such as depressed mood, social withdrawal, irritability, and insomnia (American Psychiatric Association, 1994, 541)

10. Associated medical conditions • Anorexia Nervosa- Medical Consequences • The heart muscle changes. Its beat becomes irregular resulting in heart failure and death. • Dehydration, kidney stones, and kidney failure may result. • A fine body hair, called lanugo, develops on the arms and can even cover the face. • Muscles waste away, resulting in weakness and lose of muscle function. • A lack of energy and slowed body function results delayed gastric emptying which causes bowel irritation and constipation. • Loss of bone calcium leads to osteoporosis.

11. More medical conditions • With the decrease of body weight and body fat, amenorrhea may result. • When left untreated it results in decreased bone density, and a higher incidence of stress fractures and osteoporosis. ( bone loss in an amenorrheic athlete is rapid and may not be reversible.) • Amenorrhea is defined by the absence of a menstrual cycle for at least six consecutive months. ( the absence of a regular menstrual cycle is abnormal and unhealthy.

12. Etiology • Biological Factors of Anorexia Nervosa • Eating disorders run in families. Twenty percent of anorectic patients have a family member with an eating disorder of some kind (Long, 1995). • For many years, researchers studying eating disorders have looked for abnormalities in the production and regulation of hormones and neurotransmitters by which the brain and body govern appetite and food intake. Low concentrations of the metabolites or the neurotransmitters serotonin and norepinephrine may occur in anorectic patients (Long, 1995). • Other research shows that eating disorders may also involve enkephalins and endorphines, the opiatelike substances produced by the body. The spinal fluid of patients with anorexia contains high levels of these endogenous opoids (Long, 1995).

13. Parental style and Perfectionism • Perfectionism has been linked specifically with Anorexia Nervosa (Ablard & Parker, 1997). High expectations of parents and the desire to please others may foster a belief that parental love and social acceptance are contingent upon one’s high achievement. • In a study of 127 sets of parents of academically talented children where reported achievement goals for their children (Ablard & Parker, 1997). • Most parents reported learning goals in that they were more concerned with the understanding of the material than the external indicators. • The parents who reported performance goals were more concerned about the external indicators of achievement. Children of these parents are at high risk for performance anxiety and for developing depression and anorexia.

14. Etiologies of gender differences • Women appear to be more heavily influenced cultural standards reinforcing the desirability of being thin (Davison & Neale, 1997, 214). • Male and female standards of beauty change differently over time. One study examined the differences between Playboy models, representing the men’s ideal, and Vogue models, the women’s ideal (Barber, 1998). The men’s standard of ideal thinness correlated with the women’s standard sixteen years later, indicating that changes in the standard of beauty may be determined by women. • Women are more concerned than men about being thin, are more likely to diet, and are thus more vulnerable to eating disorders (Davison & Neale, 1997, 214).

15. More about gender differences • History of sexual harrassment • There are statistically significant associations of eating disorder symptoms with sexual assault history (Laws & Golding, 1996, 579). • Of the women in the sample with a history of sexual assault, 46.5 percent thought they were too fat and 48.6 percent demonstrated anorexic symptoms. • However, of the women in the sample who did not have a history of assault, 31.8 percent thought they were too fat and 33.1 percent demonstrated anorexic symptoms (Laws & Golding, 1996, 579). • Physiological-based theory: During puberty, females develop two years before their male counterparts (Furnham & Manning, 1997). Females may attempt to minimize these differences by dieting, resulting in a hormone imbalance.

16. Cultural influences • Eating disorders appear to be far more common in industrialized societies (Davison & Neale, 1997, 215). WHY? • Parents’ views about academic performance may be related to their education level, ethnic background and parenting style (Ablard & Parker, 1997). This influences whether they support learning goals or performance goals. • Social endorsements in Western cultures of an ideal body shape, such as those found in print and film media formats, have been related to body image disturbance as well as implicated in the development of eating disorders (Cusumano & Thompson, 1997). • Women of industrialized countries are pressured to be thin, attractive, successful in the workplace and to maintain their traditional roles as nurturing homemakers (Sondon-Hagopian, 1992, 80; Heywood, 1995, 43). A fanatical management of weight is used as a means of coping with conflicting demands.

17. Treatment • Overview of the difficulties in treatment and hospitalization: • The treatment of this disorder is often difficult. This is because of the disorder’s insidious nature which wreaks havoc not only with the body, but just as seriously with the individual’s negative self-perception (Mental Health Net, 1996). • The patient is often so weak and physiological functioning is so disturbed that hospitalization is medically imperative (Davison & Neale, 1997, 221) • If a person who suffers from Anorexia Nervosa is danger of committing suicide or choking on vomit, immediate hospitalization should be carefully considered (Mental Health Net, 1996). • Cognitive-oriented therapies, focusing on issues of self-image and self-evaluation, works to change the patients’distorted body image (Mental Health, 1996).

18. Hospitalization • Hospitalization is not only necessary, but a prudent treatment intervention since it ensures that the patients do not starve themselves to death (Mental Health, 1996). • The patients must first gain weight; they are started on a liquid diet or frequent small meals and are weighed everyday (Long, 1995). • Because relapse is frequent, the patient must follow a medical plan set by a dietician who sees to it that the patient records what he or she eats and when (Long, 1995). • During three to six months of hospitalization, hypnosis is employed by some therapists but may be resisted by many anorexic who fear even a semblance of control by others. Some success is claimed by those teaching self-hypnosis and bio-feedback techniques (ANAD, 1998).

19. Medications • Medication should be carefully monitored since patients with Anorexia Nervosa may be vomiting which may have an impact on the medication’s effectiveness (Mental Health, 1995). • Prozac may work by stabilizing serotonin systems in the brain, thereby correcting the changes in brain function responsible for many of the disorder’s symptoms. Also, Anorexia Nervosa’s accompanying symptoms like depression, anxiety, obsessions, and compulsions could be linked to disturbances in serotonin, the neurotransmitter that helps regulate mood and appetite (Craig D, 1998). • Antidepressants, such as amitriptyline, are the usual drug treatment for depressive symptoms. Chlorpromazine, on the other hand, is beneficial for those individuals suffering from severe obsessions and increased anxiety and agitation (Mental Health, 1996).

20. Behavior and Family therapy • Behavior therapy includes isolating the patient as much as possible and giving him or her mealtime company, access to a television, radio, or stereo, and other privileges for eating or gaining weight (Davison and Neale, 1997, 221). • Family therapy is advocated by Salvador Minuchin. • It is based on his theory that the eating disordered child is deflecting attention away from underlying conflict in family relationships (Davison & Neale, 1997, 221) • It focuses on changing the pattern of family interaction. The length of this therapy is approximately six months, with an eighty-five to ninety percent rate of cure (ANAD, 1994).

21. Prognosis • DSM-IV: The course and outcome of Anorexia Nervosa are highly variable. Some recover fully after a single episode, some experience fluctuation in weight gain followed by a relapse, and others have a chronically deteriorating course of the illness (American Psychiatric Association, 1994, 543). • Of individuals admitted to university hospitals, the mortality from Anorexia Nervosa is over ten percent (American Psychiatric Association, 1994, 543). • A patient diagnosed with Anorexia Nervosa and Obsessive-Compulsive Disorder will not necessarily have a poorer prognosis; however, the patients whose eating disorders were most improved showed the highest reduction of obsessions and compulsions (Thiel, Zuger, Jacoby, & Schussler, 1998, 244).

22. Body Mass Index • There is an association between low body weight at referral and poor general outcome (Hebebrand, Himmelman, Herzog, Herpertz-Dahlmann, Steinhausen, Amstein, Seidel, Deter, Remschmidt, & Schafer, 1997, 567). • The mortality rate of 11 percent in patients whose body mass indexes at referral were less than 13 kg/m2 was significantly different from the rate of 0.6 percent of the patients whose body mass indexes at referral were 13 kg/m2 or more (Hebebrand et al., 1997, 567). • “Of the fourteen patients in our study who had body mass indexes less than 11 kg/m2 at referral, only seven survived” (Hebebrand et al., 1997, 567).