anorexia nervosa

n. The first criterion for anorexia nervosa is the refusal to maintain body weight at or above a minimally normal weight for age and height. The weight limit is usually characterized as weighing less than 85% of normal body weight or having a body mass index equal to or less than 17.5. Some individuals develop anorexia nervosa during early adolescence. Rather than losing weight, they remain at the same weight while their height increases.

The second criterion is an intense fear of gaining weight or becoming fat, even though underweight. These individuals make conscious attempts to be underweight. They restrict their food intake to items that contain little or no fat. They often skip meals and exercise excessively to burn calories and to raise their sense of well-being. Although these individuals are underweight, they have an intense fear of becoming overweight. Most of these individuals have never been overweight; nor are they likely to be members of families with obesity. This fear of becoming fat typically intensifies as weight loss increases.

The third criterion involves the disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight on self-evaluation, or denial of the seriousness of the current low body weight. These individuals view themselves or specific parts of their body as too big. Individuals with anorexia often perceive their size accurately; the problem arises with their judgment of the size they see. They often admit that they need to gain weight, but they do not think that their low weight is of concern and requires medical or psychiatric intervention. Common to individuals with anorexia nervosa are low self-esteem, depression, and anxiety. Depression and anorexia nervosa are highly comorbid.

In the first half of the 20th century, there were conflicting views of anorexia nervosa. Pierre Janet considered anorexia nervosa as a pure psychological disorder and categorized the disorder into two subtypes: obsessional and hysterical. Individuals of the obsessional type refused to eat because of a fear of becoming fat and of achieving psychosexual maturity. These individuals loathed their bodies and refused food in spite of intense hunger. The hysterical type was less common and involved total cessation of hunger.

In 1914, a landmark paper by Morris Simmonds described pituitary insufficiency as leading to severe weight loss in some patients. This view was widely accepted until 1930, when the writings of Berkman once again moved to the application of a psychogenic interpretation to anorexia nervosa. Berkman described the physiological disturbances as secondary to psychological disturbances.

Many of the developments in the past 30 years have been refinements of the principles of Hilde Bruch, Arthur Crisp, and Gerald Russell. Bruch proposed that selfstarvation in anorexia nervosa is a struggle for autonomy, competence, control, and self-respect. Bruch set the groundwork for modern cognitive therapy through the emphasis on the patient’s beliefs and assumptions in the conduct of psychotherapy. Crisp emphasized the importance of the developmental model, in which anorexia nervosa is rooted in the biological and psychological experiences accompanying achievement of an adult weight. According to this view, anorexia nervosa is associated with fears and tribulations of maturity. Russell emphasized the morbid fear of fatness as the underlying condition of anorexia nervosa. He suggested that in order to remove the self-perpetuating state of starvation, correction of the starvation state must take place first.

Anorexia nervosa is categorized into two subtypes: restricting type and binge-eating/ purging type. The restricting type entails that during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Individuals with anorexia nervosa rarely have complete suppression of appetite. These individuals exhibit a strong resistance to eating drives while eventually becoming preoccupied with food and eating rituals to the point of obsession. The binge-eating/purging type entails that during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior.

Most cases of anorexia nervosa emerge during adolescence, although anorexia nervosa can occur in children. Onset is before 18 in half of the cases. Onset spikes at puberty and college. Of individuals with anorexia nervosa
0.1-1% are men and 99% are women. Roughly 50% of individuals will eventually have reasonably complete resolution of anorexia nervosa; 30% will have lingering features that will continue into adulthood. Ten percent of people will develop a chronic course of anorexia nervosa, and the remaining 10% will eventually die from the disease. Anorexia nervosa is the third most chronic medical condition in adolescents and has the highest mortality rate of any psychiatric condition. The usual causes of mortality are heart attack and suicide. Underweight purgers have the highest risk of death.

Treatment for anorexia nervosa has not been very successful. Weight gain can be achieved in many patients through a combination of supportive nursing care and behavioral techniques. Pharmacotherapy has little effect in the treatment of severely ill patients. In some acutely ill individuals, improvement in body mass and general psychosocial adjustment can be achieved through cognitive behavioral, psychoeducational, and family therapy techniques. Although treatment plans can be applied to more chronic, long-standing cases, treatment gains are less successful.

Fluoxetine improves the outcome and reduces relapse after weight restoration. Fluoxetine is associated with significant reduction in core eating disorder symptoms, such as depression, anxiety, and obsessions and compulsions. Selective serotonin reuptake inhibitors (SSRIs) are not successful when individuals with anorexia nervosa are malnourished and underweight.

Although the definition of recovery is not formalized, usually an individual with anorexia nervosa is considered recovered when he/she has a stable and healthy body weight for months or years and has not been malnourished or engaged in pathological eating behavior during the period of recovery. In women who have recovered from anorexia nervosa, obsessional behaviors persist, as do inflexible thinking, restraint in emotional expression, and a high degree of self- and impulse control. The women are socially introverted, overly compliant, and limited in social spontaneity and exhibit greater risk avoidance and harm avoidance. Furthermore, individuals who have recovered from anorexia nervosa still exhibit core eating disorder symptoms, such as ineffectiveness, a drive for thinness, and significant psychopathology related to eating habits. Eventually, 54% of individuals with anorexia nervosa will convert to bulimia nervosa.

The physical signs of anorexia nervosa are inanition, bradycardia, hypotension, orthostasis, brittle hair and nails, alopecia, lanugo, decreased body temperature, dry skin, peripheral edema, and carotenodermia. In postmenarcheal females, amenorrhea, the absence of at least three consecutive menstrual cycles, takes place. A woman who menstruates only while taking birth control pills is still considered to experience amenorrhea. While women who have anorexia nervosa produce little estrogen, men with anorexia nervosa produce little testosterone. The behaviors contributing to physical complications include restriction of calories (food and fluids), starvation, excessive exercise, and caloric replacement (refeeding). Calorie restriction and/or refeeding can lead to loss of cardiac muscle and congestive heart failure. Although refeeding may cause these illnesses, if refeeding is properly executed, then it may reverse the course of the cardiac problems. Anorexia nervosa also leads to refeeding pancreatitis and constipation. Moreover, individuals with anorexia nervosa have disturbances in the endocrine and metabolic systems. Individuals have delayed onset of puberty, growth retardation, increased risk of fracture/osteoporosis, vitamin deficiency, and infertility. Furthermore, individuals exhibit dehydration, refeeding hypophosphatemia, respiratory failure, anemia, bone marrow failure, enlarged brain ventricles (pseudoarophy), and impaired thermoregulation.

Risk factors for anorexia nervosa can be divided into individual risk factors, sociocultural risk factors, and family risk factors. Risk factors for anorexia nervosa may vary with age, social class, ethnicity, and gender. They also vary with comorbidity. In different individuals, different factors may be responsible for onset, maintenance, recovery, and relapse. The individual risk factors include genetics, weight concerns, body image dissatisfaction, and dieting. Early maturation increases the chance of anorexia nervosa. Internalization of the thin ideal, the belief that thinness equals success, is a risk factor for anorexia nervosa. Moreover, individuals with anorexia nervosa tend to express perfectionism, low self-esteem, inadequate coping skills, affective disregulation (depression and mood disorders), and impulsivity.

Family risk factors include parent’s weight, especially if parent is overweight; eating disorders in the family; concerns with weight and shape in the family; problematic parenting (overprotectiveness, parental neglect,
parental absence, and parental psychopathology); and family conflict. The sociocultural risk factors include thin beauty ideal for women, the importance of appearance to success in women, media influences, gender role conflict, teasing about weight and shape, eating disorders or weight concerns among friends, and physical or sexual abuse. Although the Latino culture prefers larger body sizes and has less concern about weight, Latina women show similar rates of eating disorders compared to Caucasians. African Americans are less likely to have anorexia nervosa than Caucasians.

Although there are numerous risk factors, there are also individual, family, and sociocultural protective factors. Individual protective factors include being assertive or self-directed, success in multiple roles, good coping skills, high self-esteem, genetic predisposition to be slender, knowledge about the dangers of dieting, and participating in sports. A close, but not overdependent or enmeshed relationship with parents and a family in which there is not an overemphasis on attractiveness or weight provide a family protective factor. Sociocultural factors also provide protection against anorexia nervosa. Social support and social acceptance of a broad range of body shapes and sizes provide protection. If the culture or ethnic background values larger body sizes, the individual is less likely to develop anorexia nervosa. This also applies to close relationships with friends and romantic partners who are relatively unconcerned with body size. Although some sports may increase the risk of an eating disorder, they largely protect against onset of an eating disorder.  -TJM