ANOREXIA NERVOSA

Anorexia nervosa

Anorexia — Comprehensive overview covers symptoms, causes, treatments and more.
Definition
Ironically, as concern grows over the rise in obesity rates, some people battle the opposite problem — anorexia nervosa. People with anorexia are obsessed with food and their weight and body shape. They attempt to maintain a weight that's far below normal for their age and height. In extreme cases, they may be skeletally thin but still think they're fat. To prevent weight gain or to continue losing weight, people with anorexia may starve themselves or exercise excessively.

Although anorexia (an-o-REK-se-uh) centers around food, the disease isn't only about food. Anorexia is an unhealthy way to try to cope with emotional problems, perfectionism and a desire for control. When you have anorexia, you often equate your self-worth with how thin you are.

Anorexia can be chronic and difficult to overcome. But with treatment, you can gain a better sense of who you are, return to healthier eating habits and reverse some of anorexia's serious complications.

Symptoms
Some people with anorexia lose weight mainly through severely restricting the amount of food they eat. They may also try to lose weight by exercising excessively. Others with anorexia engage in binging and purging, similar to bulimia. They control calorie intake by vomiting after eating or by misusing laxatives, diuretics or enemas.

No matter how weight loss is achieved, anorexia has a number of physical, emotional and behavioral signs and symptoms.

Physical anorexia symptoms
Physical signs and symptoms of anorexia include:

Extreme weight loss
Thin appearance
Abnormal blood counts
Fatigue
Dizziness or fainting
Brittle nails
Hair that thins, breaks or falls out
Soft, downy hair covering the body
Absence of menstruation
Constipation
Dry skin
Intolerance of cold
Irregular heart rhythms
Low blood pressure
Dehydration
Osteoporosis
Emotional and behavioral anorexia symptoms
Emotional and behavioral characteristics associated with anorexia include:

Refusal to eat
Denial of hunger
Excessive exercise
Flat mood, or lack of emotion
Difficulty concentrating
Preoccupation with food
Anorexia red flags to watch for
It may be hard to notice signs and symptoms of anorexia. People with anorexia often go to great lengths to disguise their thinness, eating habits or physical problems.

If you're concerned that a loved one may have anorexia, watch for these possible red flags:

Skipping meals
Making excuses for not eating
Eating only a few certain "safe" foods, usually those low in fat and calories
Adopting rigid meal or eating rituals, such as cutting food into tiny pieces or spitting food out after chewing
Weighing food
Cooking elaborate meals for others but refusing to eat
Repeated weighing of themselves
Frequent checking in the mirror for perceived flaws
Wearing baggy or layered clothing
Complaining about being fat
Causes
It's not known specifically what causes some people to develop anorexia. As with many diseases, it's likely a combination of biological, psychological and sociocultural factors.

Biological. Some people may be genetically vulnerable to developing anorexia. Young women with a biological sister or mother with an eating disorder are at higher risk, for example, suggesting a possible genetic link. Studies of twins also support that idea. However, it's not clear specifically how genetics may play a role. It may be that some people have a genetic tendency toward perfectionism, sensitivity and perseverance, all traits associated with anorexia. There's also some evidence that serotonin — one of the brain chemicals involved in depression — may play a role in anorexia.
Psychological. People with anorexia may have psychological and emotional characteristics that contribute to anorexia. They may have low self-worth, for instance. They may have obsessive-compulsive personality traits that make it easier to stick to strict diets and forgo food despite being hungry. They may have an extreme drive for perfectionism, which means they may never think they're thin enough.
Sociocultural. Modern Western culture often cultivates and reinforces a desire for thinness. The media are splashed with images of waif-like models and actors. Success and worth are often equated with being thin. Peer pressure may fuel the desire to be thin, particularly among young girls. However, anorexia and other eating disorders existed centuries ago, suggesting that sociocultural values aren't solely responsible.
Risk factors
Anorexia may seem very common because of media attention and television specials, but in truth, its prevalence is hard to pin down, partly because anorexia is sometimes defined in different ways by different researchers. Some estimates say only about 1 percent of American girls and women have anorexia. Others suggest that up to 10 percent of adolescent girls have anorexia. Anorexia is more common in girls and women. But recent research suggests that an increasing number of boys and men have been developing eating disorders in the last decade, perhaps because of growing social pressure. And while anorexia is more common among teens, people of any age can develop this eating disorder.

Although the precise cause of anorexia is unknown, certain factors can increase the risk of developing anorexia, including:

Dieting. People who lose weight by dieting are often reinforced by positive comments from others and by their changing appearance. They may end up dieting excessively.
Unintentional weight loss. People who don't intentionally diet but lose weight after an illness or accident may be complimented on their new-found thinness. Reinforced, they may wind up dieting to an extreme.
Weight gain. Someone who gains weight may be dismayed with their new shape and may get criticized or ridiculed. In response, they may wind up dieting excessively.
Puberty. Some adolescents have trouble coping with the changes their bodies go through during puberty. They also may face increased peer pressure and may be more sensitive to criticism or even casual comments about weight or body shape. All of these can set the stage for anorexia.
Transitions. Whether it's a new school, home or job, a relationship breakup, or the death or illness of a loved one, change can bring emotional distress. One way to cope, especially in situations that may be out of someone's control, is to latch on to something that they can control, such as their eating.
Sports, work and artistic activities. Athletes, actors and television personalities, dancers, and models are at higher risk of anorexia. For some, such as ballerinas, ultra-thinness may even be a professional requirement. Sports associated with anorexia include running, wrestling, figure skating and gymnastics. Professional men and women may believe they'll improve their upward mobility by losing weight, and then take it to an extreme. Coaches and parents may inadvertently raise the risk by suggesting that young athletes lose weight.
Media and society. The media, such as television and fashion magazines, frequently feature a parade of skinny models and actors. But whether the media merely reflect social values or actually drive them isn't clear-cut. In any case, these images may seem to equate thinness with success and popularity.
When to seek medical advice
Anorexia, like other eating disorders, can take over your life. You may think about food all of the time, spend hours agonizing over options in the grocery store, and exercise to exhaustion. You also may have a host of physical problems that make you feel generally miserable, such as dizziness, constipation, fatigue and frequently feeling cold. You may be irritable, angry, moody, sad, anxious and hopeless. You might visit pro-anorexia Web sites, refer to the disease as your "friend," cover up in layers of heavy clothing, and try to subsist on a menu of lettuce, carrots, popcorn and diet soda.

If you're experiencing any of these problems, or if you think you may have an eating disorder, get help. Remind yourself that you're not actually in control anymore — the anorexia is. If you're hiding your anorexia from loved ones, try to find a trusted confidante you can talk to about what's going on. Together, you can come up with some treatment options.

Unfortunately, many people with anorexia don't want treatment, at least initially. Their desire to remain thin overrides concerns about their health. If you have a loved one you're worried about, urge him or her to talk to a doctor. But unless you have legal authority to do so, you can't force loved ones to get treatment.

Tests and diagnosis
When doctors suspect someone has anorexia, they typically run a battery of tests and exams. These can help pinpoint a diagnosis and also check for any related complications.

These exams and tests generally include:

Physical exam. This may include measuring height and weight; checking vital signs, such as heart rate, blood pressure and temperature; checking the skin for dryness or other problems; listening to the heart and lungs; and examining the abdomen.
Laboratory tests. These may include a complete blood count (CBC), as well as more specialized blood tests to check electrolytes and protein as well as functioning of the liver, kidney and thyroid. A urinalysis also may be done.
Psychological evaluation. A doctor or mental health professional can assess thoughts, feelings and eating habits. Psychological self-assessments and questionnaires also are used.
Other studies. X-rays may be taken to check for broken bones, pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities. Testing may also be done to determine how much energy your body uses, which can help in planning nutritional requirements.
Diagnostic criteria for anorexia
To be diagnosed with anorexia, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DMS), published by the American Psychiatric Association.

DSM diagnostic criteria for anorexia are:

Refusal to maintain a body weight that is at or above the minimum normal weight for your age and height
Intense fear of gaining weight or becoming fat, even though you're underweight
Denying the seriousness of having a low body weight, or having a distorted image of your appearance or shape
In women who've started having periods, the absence of a period for at least three consecutive menstrual cycles
These criteria, however, are not without controversy. Some medical professionals believe these criteria are too strict or don't accurately reflect symptoms in some people. Some people may not meet all of these criteria but still have an eating disorder and need professional help. As more is learned about anorexia, the diagnostic criteria may change.

Complications
Anorexia can have numerous complications. At its most severe, it can be fatal. Anorexia has one of the higher death rates among all mental illnesses, around 5 percent but perhaps even higher than that. Death may occur suddenly — even when someone is not severely underweight. This may result from abnormal heart rhythms (arrhythmias) or electrolyte imbalances.

Complications of anorexia include:

Death
Anemia
Heart problems, such as mitral valve prolapse, abnormal heart rhythms and heart failure
Bone loss, increasing risk of fractures later in life
Lung problems resembling emphysema
In females, absence of a period
In males, decreased testosterone
Gastrointestinal problems, such as constipation, bloating or nausea
Electrolyte abnormalities, such as low blood potassium, sodium and chloride
Kidney problems
If a person with anorexia becomes severely malnourished, every organ in the body can sustain damage, including the brain, heart and kidneys. This damage may not be fully reversible, even when the anorexia is under control.

In addition to the host of physical complications, people with anorexia also commonly have other mental disorders as well. They may include:

Depression
Anxiety disorders
Personality disorders
Obsessive-compulsive disorders
Drug abuse
Treatments and drugs
When you have anorexia, you may need several types of treatment. If your life is in immediate danger, you may need treatment in a hospital emergency department for such issues as dehydration, electrolyte imbalances or psychiatric problems.

Treatment of anorexia is generally done using a team approach that includes medical providers, mental health providers and dietitians, all with experience in eating disorders.

Here's a look at what's commonly involved in treating people with anorexia:

Medical care
Because of the host of complications anorexia causes, you may need frequent monitoring of vital signs, hydration level and electrolytes, as well as related physical conditions. A family doctor or primary care doctor may be the one who coordinates care with the other health care professionals involved. Sometimes, though, it's the mental health provider who coordinates care.

Psychotherapy
Individual, family and group therapy may all be beneficial. Individual therapy can help you deal with the behavior and thoughts that contribute to anorexia. In psychotherapy, you can gain a healthier self-esteem and learn positive ways to cope with distress and other strong feelings. A type of talk therapy called cognitive behavioral therapy (CBT) is most commonly used but lacks strong evidence that it's superior to other forms of therapy. The mental health provider can help assess the need for psychiatric hospitalization or day treatment programs.

Family therapy can help resolve family conflicts or muster support from concerned family members. Family therapy can be especially important for children with anorexia who still live at home. Group therapy gives you a way to connect to others facing eating disorders. And informal support groups can also be helpful. However, be careful with group therapy. For some people with anorexia, group therapy or support groups can result in competitions to be the thinnest person there.

Nutritional therapy
A dietitian offers guidance on a healthy diet. A dietitian can provide specific meal plans and calorie requirements to help meet weight goals. In severe cases, people with anorexia may require feeding through a tube that's placed in their nose and goes to the stomach (nasogastric tube).

Medications
There are no medications specifically approved by the Food and Drug Administration (FDA) to treat anorexia since they've shown limited benefit in treating this eating disorder. However, antidepressants or other psychiatric medications can help treat other mental disorders you may also have, such as depression or anxiety.

Hospitalization
In cases of medical complications, psychiatric emergencies, severe malnutrition or continued refusal to eat, hospitalization may be needed. Hospitalization may be on a medical or psychiatric ward. Some clinics specialize in treating people with eating disorders. Some may offer day programs or residential programs, rather than full hospitalization. Specialized eating disorder programs may offer more intensive treatment over longer periods of time. Also, even after hospitalization ends, ongoing therapy and nutrition education are highly important to continued recovery.

Treatment challenges in anorexia
Anorexia occurs on a continuum. Some cases are much more severe than others. Less severe cases may take less time for treatment and recovery. But one of the biggest challenges in treating anorexia is that people may not want treatment or think they don't need it. In fact, some people with anorexia promote it as a lifestyle choice. They don't consider it an illness. Pro-anorexia Web sites are proliferating, even offering tips on which foods to avoid and how to fight hunger pangs.

Even if you do want to get better, the pull of anorexia can be difficult to overcome. Anorexia is often an ongoing, lifelong battle. It may wax or wane. Even if symptoms subside, you remain vulnerable and may have a relapse during periods of high stress or during triggering situations. For some women, for instance, anorexia symptoms may subside during pregnancy but return after pregnancy. Ongoing therapy or periodic appointments during times of stress may be helpful.

Lack of health insurance coverage also can interfere with treatment. Many health insurers don't cover lengthy treatment programs, particularly inpatient programs. Relapse rates are higher when treatment ends too soon.

Prevention
There's no guaranteed way to prevent anorexia or other eating disorders. Pediatricians may be in a good position to identify early indicators of an eating disorder and prevent the development of full-blown illness. They can ask children questions about their eating habits and satisfaction with their appearance during routine medical appointments, for instance.

If you notice a family member or friend with low self-esteem, severe dieting and dissatisfaction with appearance, consider talking to him or her about these issues. Although you may not be able to prevent an eating disorder from developing, you can talk about healthier behavior or treatment options.

Lifestyle and home remedies
When you have anorexia, it can be difficult to take care of yourself properly. In addition to professional treatment, follow these steps:

Stick to your treatment plan. Don't skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
Talk to your doctor about appropriate vitamin and mineral supplements. If you're not eating well, chances are your body isn't getting all of the nutrients it needs.
Don't isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart.
Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.
Coping and support
You may find it difficult to cope with anorexia when you're hit with mixed messages by the media, culture, and perhaps your own family or friends. You may even have heard people joke that they wish they could have anorexia for a while so that they could lose weight.

So how do you cope with a disease that can be deadly when you may be getting messages that being thin is a sign of success?

Remind yourself what a healthy weight is for your body, especially at times when you see images that may trigger your desire to restrict calories.
Don't visit pro-anorexia Web sites. These sites can encourage you to maintain dangerous habits and trigger relapses. Anorexia isn't a lifestyle choice. It's a disease, and it's probably controlling your life.
Acknowledge that you may not be the best judge of whether you're eating enough or are at a healthy weight.
Identify situations that are likely to trigger thoughts or behavior that may contribute to your anorexia so that you can develop a plan of action to deal with them.
Look for positive role models, even if they're not easy to find. Remind yourself that the ultrathin models or actors showcased in women's magazines or gossip magazines often don't represent healthy bodies.
Don't call anorexia your friend. That kind of self-deception can kill you.
Related links:
Eating disorder treatment: Know your options
Eating disorders


Last updated 12/20/2007 12:00:00 AM
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