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Anorexia
What is it?Effects of Anorexia
What causes anorexia?
Treatment of anorexia
References
What is it?
Anorexia Nervosa, commonly called anorexia, may affect about 1 in 250 of the British population, and approximately 90% of those diagnosed are female (NCCMH, 2004). Anorexia generally effects adolescents and young adults, but also occurs in children and adults. Once called "slimmer's disease," people with anorexia suffer from a profound compulsion to consume an energy deficient diet, and/or to lose weight, and/or to maintain an extremely low body weight. Formal diagnostic criteria (APA, DSM IV, 1994) state that people do not have anorexia nervosa until body weight falls below BMI 17.5 (See "What is BMI?" in Frequently Asked Questions). However, some people who lose a lot of weight may experience most of the symptoms of anorexia at higher weights, depending on their weight when weight loss commenced. The core psychological problem for individuals with anorexia is that they evaluate themselves primarily on their ability to lose weight, to limit their diet, or to be uncommonly thin; and their capacity to evaluate themselves on other personal characteristics is diminished.
Anorexia falls into two subtypes: Restricting and Purging (APA, DSM-IV, 1994). People with the restricting subtype tend to use calorie restriction and in some cases, excessive exercise for weight control. Those with the purging subtype may experience episodes of objective or subjective overeating or binge eating, for which they compensate with vomiting, laxative or diuretic abuse in misguided attempts to avoid the absorption of calories. These compensatory behaviours are commonly referred to as "purging." Some people with the purging subtype habitually engage in purging behaviour without overeating. The purging subtype of anorexia is sometimes misdiagnosed as bulimia. The main factor that differentiates anorexia-purging subtype from bulimia is the individual's weight. People with anorexia tend to be significantly underweight whereas the weight of people with bulimia tends to fall within the healthy range.
Effects of Anorexia
A proportion of women with abnormally low body weight lose their periods, causing infertility. This condition generally reverses when sufficient weight is regained. Males with anorexia have reduced sexual function. People with anorexia tend to experience low mood, anxiety, repetitive thoughts, ritualistic or compulsive behaviours with food and eating (and possibly with other areas of their lives as well), and preoccupation with thoughts and behaviours relating to food, eating and weight control. They tend to believe that their inadequate diet is best for them and fear that even the smallest change will cause weight gain. People with anorexia tend to believe body parts are larger than they actually are. They live with an internal emotional climate of fear and anxiety for which they tend to believe the only remedy is to eat even less or to lose more weight. Anorexia causes significant disruption to the individual's relationships, education and employment. Family members and friends can find that caring for the person with anorexia can be an extremely stressful experience.
Starvation causes brain shrinkage and bone demineralisation. Loss of essential body fat and muscle leaves people with anorexia feeling cold and weak (Zerbe, 1995). Prolonged malnutrition and starvation can in some cases lead to organ failure. Purging by vomiting or laxative abuse can lead to electrolyte imbalance. Electrolytes are essential minerals, including potassium, sodium, chloride and magnesium. A fine balance of electrolytes in the body is necessary for normal nerve and muscle function and proper fluid regulation. Electrolyte imbalance can lead to disturbance in cardiac function, neurological problems, generalised weakness, confusion and memory impairment, mood swings, and ultimately, cardiac arrest or kidney failure. Frequent vomiting causes erosion of tooth enamel, inflammation of the salivary glands and oesophageal damage. Laxative abuse can lead to physical and emotional dependence, intestinal damage, electrolyte imbalance and cardiac irregularity (Zerbe, 1995). Children and adolescents with anorexia experience impaired emotional and social development (Lock, et. al., 2001). They may also experience delayed or arrested puberty and permanently stunted growth (NCCMH, 2004).
Anorexia has the highest mortality rate of all mental health disorders. While a proportion of fatalities are related to organ failure and other medical complications related to starvation or purging, suicide is the most common cause of death (NCCMH, 2004).
What causes anorexia?
Anorexia seems to be caused by a combination of individual physical, psychological and social vulnerabilities. Research suggests some individuals may have a genetic or hereditary vulnerability to anorexia (Campbell et.al., 1999). Dieting behaviour alone can trigger anorexia if weight loss is rapid and achieved by a highly calorie-restricted diet which is sustained over a period of months. Illness or dieting that causes body weight to fall below BMI 19 may also trigger anorexia. Psychological vulnerabilities may include family discord or high parental expectations; and/or a personal history of depression, anxiety, low self-esteem, perfectionism, obsessive or compulsive traits; body-image preoccupation and dieting (Pike et. al., 2008). Family risk factors may include having a parent or other close family member who has negative body image or dieting; psychological illness, or drug or alcohol abuse. Social vulnerabilities include being female, social pressure to be thin (McKnight Investigators, 2003), being bullied about weight or being overweight as a child, the demands of life-stage transitions (such as starting university or leaving home), experience of loss (such as parental separation or the death of a loved one), or experience of abuse or trauma (Lock, et.al., 2001).
Back to topTreatment of anorexia
Inadequate research has been published on the causes and treatment of anorexia (because it is a relatively rare disease), and to this day anorexia remains notoriously difficult to treat successfully. This is for several reasons. Firstly, people with anorexia tend to place a high personal value on being underweight, which they rigidly hold on to despite the negative consequences of the illness. Physiologically, the state of being significantly underweight causes changes in thinking and perception which tends to cause people with anorexia to ignore the medical, psychological and social effects of their pursuit of thinness. Indeed, some people with anorexia deny having problems that are obvious to others, and avoid (or actively resist) getting help or making changes. Additionally, the symptoms of anorexia are self-perpetuating. Those with anorexia become highly preoccupied with their efforts to under-eat and burn calories. They become terribly afraid of gaining weight and may go to extreme lengths to avoid this. The unfortunate consequence is that their anxieties and preoccupations actually get worse and lead to a further increase in the value placed on being extremely thin. Therefore, people with anorexia tend not to want to take an essential step towards getting better, which is to improve nutritional intake and regain weight.
Some individuals with anorexia will, with encouragement from family or health practitioners, engage with treatment out of concern for the damage the illness is causing to their health, relationships, social functioning or future plans (NCCMH, 2004). A proportion of those who do access treatment will not complete it due to their aversion to having to gain weight in order to achieve full recovery. Unfortunately some people with anorexia may refuse treatment entirely; and a small proportion of those with severe or life-threatening anorexia require compulsory treatment under the Mental Health Act.
The most successful approaches to treating anorexia combine weight restoration with psychological education and active psychological change, and research suggests that antidepressant medication such as fluoxetine may be useful in improving outcome and preventing relapse after weight restoration (Kaye, et.al., 2001). Weight restoration without active psychological intervention tends to result in relapse; and psychological intervention without weight restoration tends to result in limited progress due to the cognitive and behavioural rigidity caused by being underweight. Early intervention (i.e. within the first two years of onset) invariably predicts better outcomes than later intervention. Therefore, adolescents with anorexia generally have good treatment outcomes while adults who have had anorexia for five years or longer are more likely to have poor treatment outcomes (Fairburn, 2005).
Mild to moderate anorexia should be treated by community-based multidisciplinary care teams including GPs, dieticians and specialist psychotherapists, counsellors or psychologists (NCCMH, 2004) (DoH: NSFCYPMS, 2004). Community psychiatrists with knowledge of the treatment of eating disorders may also be able to help. Severe anorexia, however, warrants hospital-based medical and psychiatric care in a specialist eating disorders unit. Placing individuals with severe eating disorders on mixed-diagnosis psychiatric wards can be counterproductive (Worrall, et.al., 2004). The definition of severe anorexia includes BMI below 15 or weight loss of 0.5 kg per week for 4 weeks or medical instability or psychiatric risk. Local Primary Care Trusts should have established criteria for mild, moderate and severe anorexia, along with the corresponding commissioned care pathway (DoH: NSFCYPMS, 2004), but, in reality, treatment for eating disorders in the UK remains patchy, and lacks uniformity in clinical management structures (Palmer and Treasure, 1999).
References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association.
Campbell, D.A., Sundaramurthy, D., Gordon, D., Markham, A.F., and Pieri, L.F. (1999). Association between a marker in the UCP-2/UCP-3 gene cluster and genetic susceptibility to anorexia nervosa. Molecular Psychiatry, 4, 68-70.
Department of Health (2004). CAMHS Standard, National Service Framework for Children, Young People and Maternity Services. The Mental Health and Psychological Well-being of Children and Young People.
Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. London: Guilford.
Kaye, W. H. Nagata, T., Weltzin, T.E., Hsu, L.K.G., Sokol, M.S., McConaha, C., Plotnicov, K.H., Weise, J. and Deep, D. (2001). Double-blind placebo-controlled administration of fluoxetine in restricting- and restricting-purging-type anorexia nervosa. Biological Psychiatry, 49, 644-652.
Lock, J., Le Grange, D., Agras, W.S. and Dare, C. (2001). Treatment Manual for Anorexia Nervosa: A Family-Based Approach. London: Guilford.
McKnight Investigators (2003). Risk factors for the onset of eating disorders in adolescent girls: Results of the McKnight Longitudinal Risk Factor Study. American Journal of Psychiatry, 160, 248-254.
National Collaborating Centre for Mental Health (NICE) (2004). Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. National Clinical Guideline No. CG9. BPS and Gaskell.
Palmer, R.L. and Treasure, J. (1999). Providing specialised services for anorexia nervosa.British Journal of Psychiatry, 175, 306-309.
Pike, K.M., Hilbert, A., Wilfley, D.E. , Fairburn, C.G., Dohm, F.-A., Walsh, B. T. and Striegel-Moore, R. (2008). Towards and understanding of risk factors for anorexia nervosa: a case-control study. Psychological Medicine, 38, 1443-1453.
Worrall, A., O'Herlihy, A., Banerjee, S., Jaffa, T., Lelliott, P., Hill, P. (2004). Inappropriate admission of young people with mental disorder to adult psychiatric wards and paediatric wards: cross sectional study of six months' activity. British Medical Journal, 328, 867.
Zerbe, K.J. (1995). The Body Betrayed: Women, Eating Disorders, and Treatment. Carlsbad, CA, USA: Gurze Books.