ABSTRACT
Anorexia nervosa (AN) is a type of eating disorder, but it is more importantly a serious psychiatric illness associated with significant medical and psychiatric morbidity, psychosocial impairment and increased risk of death. The clinical features are characterized by deliberate weight loss, arising from food avoidance often in combination with self-induced vomiting, excessive exercise and using diuretics and appetite suppressants.
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria is used to determine if the patient is suffering from anorexia nervosa. Anorexia can have dangerous psychological and behavioral effects if left untreated. The treatment of anorexia has to focus on more than weight gain and the physical damage caused by malnutrition. It must also focus on the psychological cause.
Keyword: Anorexia nervosa, eating disorders, psychotherapy
INTRODUCTION
Anorexia nervosa is an eating disorder that is characterized by determined dieting, often accompanied by compulsive exercise, and purging behavior resulting in sustained low weight and this usually begins in adolescence and. Other features include disturbed body image, heightened desire to lose more weight, and pervasive fear of fatness.1
The causes appear to be multifactorial, with determinants including genetic influences, personality traits of perfectionism and compulsiveness, anxiety disorders, family history of depression and obesity, and peer, familial, and cultural pressures with respect to appearance. These contribute to an unshakable overvaluation of slimness, distorted perceptions of body weight, and phobic avoidance of many foods.1
Other psychiatric conditions that often coexist with anorexia nervosa are, major depression, anxiety disorders and obsessive–compulsive disorder. Anorexia nervosa is associated with an array of life threatening health complications, such as heart arrhythmias, hypotension, and hypoglycemia.1,2
Anorexia nervosa can be treated through many approaches but mainly pharmacologic and psychological treatments designed to target the core features that defines anorexia nervosa (weight, appetite, distorted thoughts, and behaviors).3
DEFINITION
Anorexia nervosa is a serious psychiatric illness defined in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as a refusal to maintain minimally normal body weight, an intense fear of gaining weight or becoming fat, cognitive disturbances regarding one’s body weight and shape, and amenorrhea in postmenarcheal females.3
EPIDEMIOLOGY
Anorexia nervosa mainly affects adolescent girls and young. In developed societies, a slight bias toward higher socio-economic status is common. Anorexia has an average prevalence of 0.3–1% in women and 0.1% in men for the diagnosis in developed countries. The condition largely affects young adolescent women between the ages of 15 and 19 years old making up 40% of all cases. Approximately 75% of people with anorexia are female. Anorexia nervosa is thought to be rare in less-developed countries.4
ETIOLOGY
The exact cause of anorexia nervosa is unknown, although most believe that it stems from a mixture of social, psychological and biological factors. People affected by this disorder are frequently over-achievers with very low self-esteem often with feelings of fatness and unattractiveness and who do not feel that they are in control of their lives. They are often the “perfect” children of unusually industrious, conscientious, motivated parents. These parents tend to have a strong sense of decorum and high standards of accomplishment.5
Although these families may appear normal to outsiders, they place great emphasis on outward appearances and visible evidence of achievement, while the quality of interpersonal communication among family members tends to be inadequate. The parents of these patients are frequently over-demanding, self-made, overprotective, and preoccupied with appearances. Both parents often put a great deal of pressure on the child to succeed and hence directing the child to develop a series of insecurities and unattractiveness.5
Besides that, low self esteem results in poor relations with their peers. Frequently, these anorexic patients have never rebelled in any normal way and asserted their independence from their parents, possibly because of fear of punishment. It has been suggested that this fear of punishment combined with fear of being unable to live up to their own expectations of perfection may be the reason they strive so vigorously to succeed and please their parents causing them to find comfort by starving and looking good through their own way.5
Many investigators believe that girls or sometimes even guys are wrongly exposed, especially to media outlets where the pressure to be thin is so widespread and by becoming anorectic they then feel accepted and looking like how their role models look on the social media.5
Other authors believe that the roots of anorexia nervosa can be traced to the child’s inability to distinguish normal hunger sensations because of inappropriate feeding patterns in infancy. It is postulated that the mothers of these girls may have reacted to crying due to stress or pain during infancy by offering food, so that the baby learned to eat in response to improper environmental signals. Thus, the anorectic may not recognize or trust her own legitimate body signals of hunger and question the legitimacy of other natural physical feelings as well.5
These feelings of uncertainty about bodily sensations may lead to a fear of not being able to control these functions. The girl may consider eating, as well as other physically enjoyable functions, to be evidence of personal weakness. In many anorectics, these misconceptions are compounded by feelings of unworthiness, helplessness, and a tremendous sense of guilt for some unidentifiable wrongdoing. Their anorexia may have a strong self- destructive component.5
Although the psychological basis of anorexia nervosa is widely accepted, possible genetic factors are currently being studied. So far, however, the information is not sufficient to establish a relationship between anorexia and mood disorders or other genetic factors.5
CLINICAL FEATURES
Anorexia nervosa is characterized by an abnormally low body weight, intense fear of gaining weight, distorted perception of body weight and shape, and amenorrhea. Anorexia nervosa is more common in women than men. The onset is between the ages of 12 and 25 and is predominantly in middle to upper class families. No matter how weight loss is achieved, anorexia has a number of physical and behavioral signs and symptoms.5,6
Behavioral Characteristics
Anorexia nervosa starts with various ways and one most often is when an overweight teenager who is oversensitive about being plump begins a weight loss diet that soon escalates into an uncontainable preoccupation with food and the pursuit of thinness.
In these patients, the act of eating causes extreme anxiety amounting to a phobic disorder. Severe restrictions and measures of weight loss take place with drastically reduced caloric intake followed by self-induced vomiting or the abuse of laxatives are methods used. Both of these forms of weight control are often accompanied by hysterical exercise programs.5,6
Anorectics drastically reduce their overall caloric intake, but more specifically, they disproportionately decrease the carbohydrates and fat in their diet. Their obsessive eating habits include a detailed knowledge of the caloric value and composition of food that enables them to intentionally choose a diet that is low in calories.5,6
As a general rule, the anorectic patient persistently denies hunger, although the obsession with the preparation and handling of foods belies this. The preoccupation extends to the elaborate planning and preparation of meals for family and friends, although the patients will not participate in these meals themselves.
These patients will practice deceit, often concealing uneaten food or lying about food intake. They typically refuse to eat in public, but will frequently hoard carbohydrate-rich foods such as cookies and candy in their rooms or in their pockets or purses. If they are forced to eat in public, they will either dispose of the food stealthily or will make a great fuss over the food, often cutting it into very small pieces and demonstrating an almost ritual-like behavior in separating the elements of the food.5,6
It has been suggested that far from not being hungry, these patients have learned to enjoy hunger because of the sense of self-control it gives them, compensating for the lack of control they feel in other areas of their lives. Their absolute control over their appetites makes them feel morally pure and superior.5,6
Physical Findings
Physical manifestations of anorexia nervosa include amenorrhea, dehydration, decreased body temperature, hypotension, and bradycardia. Loss of subcutaneous fat and normal body contours also occur. The abdomen is markedly scaphoid, and the skin is dry and rough. Despite the dramatic weight loss, the degree of emaciation may not be apparent when the patient is fully dressed because of edema in the legs and parotid enlargement, which gives fullness to the face.5,6
Cessation of ovulatory menses may predate weight loss in up to 25% of patients. For this reason, some endocrinologists suspect a neuroendocrine malfunction that could also be the source of the disturbances in blood pressure and temperature regulation, abnormal eating behavior, sexual disinterest, and hormonal changes. Other evidence, however, indicates these neuroendocrine abnormalities are secondary to malnutrition.5,6
Decreased estrogen production may lead to the development of osteoporosis, and clinical and laboratory studies may show nutritional anemia, decreased white blood cell and platelet counts, vitamin and mineral deficiencies, impaired renal function, electrolyte imbalances, and hypothyroidism.
Subsequently, these patients often lose the ability to maintain normal body temperature in the presence of heat or cold. The impaired renal function brought about by chronic starvation, self-induced vomiting, and abuse of diuretics and laxatives may cause death in some patients due to abnormal blood chemistry levels.5,6
When these patients do eat, they will often gain weight rapidly due to fluid retention in the tissues, which causes swelling of the ankles, legs, face, and hands. The digestive system is also slowed in anorexia nervosa patients, leading to postprandial bloating, sensations of fullness, abdominal pain, and constipation due to slowed intestinal action. Their inability to tolerate food because of these symptoms will further force these patients to avoid food.5,6
DIAGNOSIS
The diagnosis of anorexia nervosa is made on the basis of history taking which includes information from family members, friends, and teachers that reveals overvaluation of thinness and abnormal food restriction, compulsive exercise, and sometimes binging and purging and on the basis of a physical examination revealing excessive thinness. Purging is suggested by enlargement of the salivary glands, eroded dental enamel, and scars on the dorsum of the hands from repeated, self-induced vomiting.1
In the most recent version of the DSM (DSM-IV-TR), anorexia nervosa is classified under Eating disorders, meeting the criteria in establishes the diagnosis.2
Diagnostic Criteria for Anorexia Nervosa (DSM-IV-TR):
- Refusal to maintain body weight at or above 85% of normal weight for age and height.
- Intense fear of gaining weight or becoming fat, despite being underweight.
- Disturbances in the way in which body weight or shape is experienced, undue influence of body shape or weight on self-evaluation, or denial of the seriousness of current low body weight.
- Amenorrhea in post-menarcheal girls and women (missing at least 3 consecutive menstrual cycles or having periods only after administration of a hormone such as estrogen).
MANAGEMENT
Anorexia nervosa can be treated through methods such as psychotherapy and/or prescription drugs. Management of anorexia nervosa involves three important components include restoring the person to a healthy weight, treating the psychological issues related to the eating disorder, reducing or eliminating behaviors or thoughts that lead to insufficient eating and preventing relapse.
Treatment is usually given on an outpatient basis, inpatient treatment being indicated only if weight loss is severe (for example, less than 65% of normal) or if there is risk of death from medical complication or from suicide. There is a limited evidence base for treatment, although individual psychological treatments, particularly cognitive behavior therapy (CBT) and family therapy are used.7,8
Psychological treatments
A variety of psychological treatments for AN have attempted to target different aspects of the disorder, including distorted thoughts regarding food and body image, dysfunctional behaviors such as restrictive eating, binging and purging, and interpersonal issues. To date, CBT has been the most frequently studied psychological treatment for AN in adults, and family therapy has gained evidence for the treatment of AN in adolescents.3,7
Cognitive behavioral therapy
CBT for AN is based on a model that overvalued ideas about the implication of shape, weight, and control over eating are the maintaining factors of the disorder. In general, the treatment can be divided into four phases which are enhancement of motivation, targeting of cognitive distortions and dysfunctional behavior related to eating habits and shape or weight, issues beyond eating and weight, and relapse prevention. CBT concentrates on thinking about how a person feels and behaves. The goal of CBT is to learn how to replace distorted thoughts of the world and self with those that lead to a pleasing reaction.3,7
Family therapy
Family therapies are where family members are invited to become part of the treatment team to extend a therapeutic environment for change into patient’s naturalistic environments. Family therapy helps to stabilize relationships and therefore provide a more supportive environment. Family therapy appears superior when compared with other forms of psychotherapy, and results do not appear dependent on the format (e.g., individual versus group) or length of treatment.
Early theories of the development of AN assumed that dysfunctional family life were one of the causes of the disorder. As such, family therapy interpreted patients with AN as the “identified patient” and sought to treat the family system because the entire family was viewed as the actual patient. In stark contrast, the current rationale for family therapy does not blame the family for the emergence of AN, and instead is based on the idea that the family environment can be used to ameliorate the disorder. 3,7
Antidepressants
The most prominently studied drug class for AN is antidepressants. Antidepressants have shown efficacy in the treatment of several Axis I disorders including major depression and obsessive compulsive disorder. Based on shared features between AN and disorders that respond favorably to treatment with antidepressants, different classes of antidepressants, including tricyclics (TCAs) and selective serotonin reuptake inhibitors (SSRIs), have been evaluated in the treatment of AN. Overall, the TCA class of antidepressants appears to be ineffective in the treatment of AN, with some specific medications (ie, amitriptyline) associated with significant side effects. On the other hand, the SSRI class of antidepressants appears well tolerated by AN patients, with only mild side effects. However, SSRIs do not appear to be effective in treating symptoms of AN or preventing relapse.3,8
Antipsychotics
Various antipsychotics have been evaluated in the treatment of AN, because affected individuals show distorted body image to a delusional proportion and because of the ego-syntonic nature of self-starvation. Furthermore, antipsychotics are known to reduce agitation and anxiety and often have weight gain as a side effect.
Although antipsychotics appear to be reasonably well tolerated by individuals with AN, some are associated with severe side effects, and those associated with the worst side effects do not appear to be associated with large improvements in treating the disorder. Of note, preliminary evidence suggests that olanzapine is well tolerated, associated with only mild side effects, and may be effective in improving some cognitive symptoms and weight.3,8
Other agents
Other pharmacologic agents have been tried in the treatment of AN, including lithium carbonate (a mood stabilizer), cyproheptadine hydrochloride, and cisapride. Similar to some of the antipsychotic medications, lithium carbonate and cyproheptadine were evaluated in the treatment of AN because of their associations with weight gain.
On the other hand, cisapride was evaluated in AN due to its known effect on increasing the rate of gastric emptying, which was hypothesized to decrease distress from feelings of fullness and bloating during refeeding.3,8
PROGNOSIS
Psychological abnormalities persist in one third to one half of anorexia nervosa patients after two years of follow-up. During this time, relapses and remissions are common. Follow-up studies indicate that 60% of patients will continue to have behavioral eating problems after treatment ceases.
Since social maladjustment and impaired family relations persist in as many as 50% of these patients, long-term psychotherapy and/or medical supervision may be necessary to control diet and weight loss. Often these women may seem to have recovered and may function well at work but will remain socially maladapted, placing them at risk for relapse.5
The prognosis is best when associated with early age of onset, sudden onset, short duration of illness, weight loss of less than 30%, no use of laxatives or vomiting, admittance of hunger and appetite, little sleep disturbance, and minimal denial of illness.
Indicators of a poor prognosis include long duration of illness or amenorrhea, older age at onset, very low weight during illness or at diagnosis, previous psychiatric treatment, lower socioeconomic family status, married status, disturbed relationship with parents, and poor outcome after one year.
Treatment of patients with anorexia nervosa is a long-term process. Relapses and failure are common and require perseverance on the part of the patient, the family, and the physician. However, with recent therapeutic methods, the mortality rate from this disease has decreased from between 10% and 30% to between 3% and 5%, although some patients still die of starvation, suicide, and medical complications such as sudden death and stomach rupture.5
CONCLUSION
Anorexia nervosa is one type of eating disorder, but it is more importantly a psychological disorder. Approximately 95% of those affected by anorexia are female and are common in middle and upper socioeconomic groups. While most anorexia begins in early adolescence, it is also seen in young children and adults. A cause for anorexia has yet to be determined at this time. Anorexia nervosa is difficult to diagnose. Most individuals with the disorder will go to great measures to hide what they are doing. It is unusual for them to seek professional help because they are in denial about the problem.
In most cases the actual diagnoses is not made until other medical complications have developed. Many times a family member is responsible for getting help and letting the health-care professional know the degree of weight loss. Anorexia nervosa is defined in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as a refusal to maintain minimally normal body weight, an intense fear of gaining weight or becoming fat, cognitive disturbances regarding one’s body weight and shape, and amenorrhea in postmenarcheal females.
Anorexia can have dangerous psychological and behavioral effects. The individual can become depressed and irritable and have difficulty interacting with others leading to social withdrawal. Sleep can become disrupted causing fatigue during the day.
Attention and concentration can decrease. There are also medical complications from anorexia most resulting from starvation. These include heart–rhythm disturbances, digestive complications, bone density loss, anemia, and hormonal and electrolyte imbalances. Some of these complications can be life threatening. Anorexia may be treated in an outpatient setting, or hospitalization may be necessary.
At this time there is no medication that can definitively reduce the compulsion to starve them, there are medications that can be used to stabilize moods, and manage some of the emotional symptoms like anxiety and depression that can accompany anorexia.
The treatment of anorexia has to focus on more than weight gain and the physical damage caused by malnutrition. It must also focus on the psychological cause. Different kinds of psychological therapy have been used to treat people with anorexia. Those that have been successful include individual therapy, cognitive behavior therapy, group therapy, and family therapy.
REFERENCES
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3. Bodell LP, Keel PK. Current treatment for anorexia nervosa: efficacy, safety and adherence. Dovepress. 2010;3:91-108.
4. Rahkonen AK, Hoek HW, Susser ES, Linna MS, Sihvola E, Raevuori A, et al. Epidemiology and course of anorexia nervosa in the community. Am J Psychiatry. 2007;164:1259-65.
5. Bohannon NJV. Anorexia nervosa. Journal of Osteo Med. 2003;1:1-6.
6. Bernstein BE, Pataki C. Anorexia nervosa clinical presentation [Internet]. [Place unknown]: WebMD Professional; [Date unknown] [updated 2012 Aug 6]. Available from: http://emedicine.medscape.com/article/912187-clinical
7. Duvvuri V, Kaye WH. Anorexia nervosa. Fall. 2009;7:455-62.
8. Hay P. Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa. Aust and NZ J of Psychiatry. 2004;38:659-70.
Last Updated on 24 Agustus 2022
