Anorexia Nervosa

Also Listed As: Eating Disorders, Anorexia

People who intentionally starve themselves into an emaciated state yet remain convinced that they are overweight are suffering from a condition known as anorexia nervosa. Anorexia is a severe emotional disorder that is increasingly common, especially among young women in industrialized countries where cultural expectations encourage women to be thin. Fueled by popular fixations with thin and lean bodies, anorexia is also affecting a growing number of men, particularly athletes and those in the military. People with anorexia are terrified of becoming obese and refuse to maintain a normal weight, putting themselves in danger of starvation.

Anorexia rarely begins in people who are older than 40 years of age. It most commonly appears in the teenage years, affecting up to 3 in 100 adolescents. Although anorexia seldom emerges before puberty, associated mental conditions, such as depression and obsessive-compulsive behavior, are usually more severe when it does. The onset of anorexia is often preceded by a traumatic or stressful event and it is usually accompanied by other emotional difficulties. Anorexia is a life-threatening condition that can result in death from starvation, heart failure, electrolyte imbalance, or suicide.

There are two main types of anorexia nervosa:

• Restricting Type—characterized by dieting, fasting, and/or excessive exercise
• Binge-Eating/Purging Type (anorexic-bulimic)—characterized by self-induced vomiting and/or misuse of laxatives, enemas, and/or diuretics. Binge eating may or may not occur; purging is common even after small amounts of food have been eaten. This type carries greater medical risk.

Signs and Symptoms

The primary sign of anorexia nervosa is severe weight loss, accompanied by any number of physical and psychological symptoms and unusual behaviors related to food, eating, or exercise. A person for whom a healthy weight would be 125 pounds, for example, may drop 20, or even as much as 60 pounds below this. At the same time, the person may insist that he or she is overweight.

Physical Signs

• Scanty or absent menstrual periods
• Thinning hair
• Dry skin
• Cold or swollen hands and feet
• Bloated or upset stomach

Psychological Signs

• Distorted perception of self (that is, a great difference between how an individual believes he or she looks and his or her actual physical appearance)
• Inability to remember things
• Poor judgment
• Refusal to acknowledge the gravity of the illness
• Obsessive-compulsive behavior (excessive need to control personal environment)
• Depression (feelings of ineffectiveness; loss of interest in friends and former activities; lack of spontaneity; rigid thinking; lack of initiative; flattened emotional response; irritability; insomnia; diminished interest in sex)

Behavioral Symptoms

• Unusual behaviors related to food or eating (for example, hoarding or concealing food, refusing to eat in public, eating only one type of food, ritually cutting food into tiny pieces, intense study of diets and calories, planning and preparing elaborate meals for others)
• Compulsive exercising
• Preoccupation with body size or body image
• Preoccupation with weight control, dieting

Causes

There is no specific cause of anorexia. Medical experts agree that several factors work together in a complex fashion to lead to the eating disorder. These may include:

• Severe trauma or emotional stress (such as the death of a loved one or sexual abuse) during puberty or prepuberty.
• Abnormalities in brain chemistry. Changes in serotonin levels, a brain chemical that regulates appetite, may contribute to other symptoms of anorexia nervosa such as depression, impulsiveness, obsessive behaviors, or other mood disorders. In addition, the process of purging may deplete tryptophan, an amino acid necessary for the production of serotonin, leading to further imbalances.
• A cultural environment that puts a high value on thin or lean bodies.
• Overbearing, controlling, and critical parents who do not show emotional warmth.
• A tendency toward perfectionism, fear of being ridiculed or humiliated, a desire to always be perceived as being "good." A belief that being perfect is necessary in order to be loved. Because perfection is impossible, the inability to attain perfection reinforces the person's sense of being unworthy of being loved. Not eating, according to some experts, is a passive act of revenge directed toward those who will never love the person because of his or her lack of perfection.
• Family history of anorexia. About one-fifth of those with anorexia have a relative with an eating disorder. In fact, it is common to discover that someone with anorexia has a mother or sister with this eating disorder as well. If one identical twin has anorexia, the other has more than a 50% chance of also developing it. It is not clear, however, to what extent this family connection is due to heredity and or to learned behavior.
• Infection. Some researchers report an association between beta-hemolytic streptococcal infection or Epstein Barr virus (the virus that causes mononucleosis) and development of anorexia.

Risk Factors

• Age and gender—anorexia is most common in teens and young adult women
• Early onset of puberty
• Living in an industrialized country
• Depression—although depression is associated with the development of anorexia, it does not cause the disorder. Depression in a family member also appears to increase the likelihood of developing an eating disorder.
• Obsessive-compulsive disorder (OCD) or other anxiety disorders—OCD is present in up to two-thirds of people with anorexia. OCD associated with an eating disorder is often accompanied by a compulsive ritual around food (such as cutting it into tiny pieces); phobia, another type of anxiety disorder that may also be present in someone with an eating disorder, and/or OCD tend to emerge before the eating disorder while panic attacks may develop after the diagnosis is made.
• Avoidant and/or narcissistic personality disorder(s)—approximately one-third of those with the restricting type of anorexia have avoidant personalities, which is characterized by feelings of inadequacy, social inhibition, extreme sensitivity to negative comments or criticism, and avoidance of interpersonal relationships, both at work and on an intimate level. Borderline personality disorder (exceptionally unstable interpersonal relationships, extremely poor self-image, and excessively impulsive behaviors) may be a risk factor as well but such individuals are more likely to develop bulimia.
• Participation in sports and professions that put emphasis on a lean body (such as dance, gymnastics, running, figure skating, horse racing, modeling, wrestling, acting)
• Difficulty dealing with stress (pessimism, tendency to worry, refusal to confront difficult or negative issues)
• History of sexual abuse or other traumatic event
• Dieting

Diagnosis

While your healthcare provider will rely on points discussed in Signs and Symptoms such as excessive weight loss, refusal to maintain normal body weight, and distorted self-perception, he or she will also ask a series of questions to better determine whether or not anorexia is present. The SCOFF questionnaire, developed in Great Britain, is proving to be a very reliable method for diagnosing anorexia. A "yes" response to at least two of the following questions is a strong indicator of an eating disorder:

• S "Do you feel sick because you feel full?"
• C "Do you lose control over how much you eat?"
• O "Have you lost more than 13 pounds recently?"
• F "Do you believe that you are fat when others say that you are thin?"
• F "Does food and/or thoughts of food dominate your life?"

If an eating disorder is suspected, the healthcare provider will order a number of laboratory tests. These serve to determine blood count (to assess for signs of anemia that may be related to lack of iron or vitamin B12), levels of electrolytes (minerals such as potassium, calcium, and magnesium), amylase (serum amylase is elevated when there is frequent vomiting), and protein, and kidney, liver, and thyroid functions. He or she may also order an electrocardiogram (which gives a graphic record of the electrical activity of the heart); this may be abnormal if there is a deficiency in an electrolyte or nutrient such as potassium or calcium. If a diagnosis of anorexia is made, the healthcare provider will require frequent office visits to monitor the condition. It is best for a person with anorexia to work with a multidisciplinary team including his or her primary care physician, a psychologist or psychiatrist, and a registered dietitian.

Preventive Care

The most effective prevention strategy is the development, from an early age, of healthy eating habits and a strong body image. Cultural values that place a premium on lean or thin bodies need to be questioned. Education about the life-threatening nature of anorexia is also an important part of prevention.

In those who have already been diagnosed and treated for anorexia, avoiding recurrence of the eating disorder is the primary goal.

• Family and friends should be urged not to focus on the patient's condition or on issues of food or weight. Mealtimes, for example, should be reserved for social interaction and relaxation, without any discussion of the disease.
• Careful and frequent monitoring of weight and other physical signs by the healthcare provider can reveal signs of a relapse.
• Cognitive or other forms of psychotherapy can help the person to develop coping skills and change the unhealthy thought processes that underlie anorexia nervosa.
• Family therapy is helpful in addressing underlying contributing factors in the home environment and in enlisting the support and understanding of family members.

Treatment Approach

Anorexia demands a multipronged treatment plan that addresses both the physical and psychological aspects of this disorder. Cognitive-behavioral therapy, often in combination with antidepressants, is a very effective therapeutic approach for treatment of eating disorders. Complementary and alternative methods of treatment (such as the use of herbs and mind/body medicine) are valuable adjuncts to usual ways of stimulating appetite, addressing nutritional problems, and helping the patient to develop a healthier body image and to learn to deal more productively with stress.

In general, the most important aspect of treating anorexia is restoring weight and preventing starvation. For this, hospitalization may be necessary, particularly under the following circumstances:

• Continuing weight loss, in spite of outpatient treatment
• Body mass index (BMI; a measurement that takes into account a person's height and weight) 30% below normal; normal range is 19 to 24
• Irregular heart rhythm
• Severe depression
• Suicidal tendencies
• Low potassium levels
• Low blood pressure

Generally, adequate weight gain (1 to 2 pounds per week) and appropriate changes in behavior require a 10 to 12 week hospital stay. (Most insurance in the United States, however, covers only 15 days of inpatient treatment.) To avoid bloating, abdominal upset, and fluid retention, those who are severely malnourished may be started on a diet of 1,500 calories a day, gradually increasing to as much as 3,500 calories. Because anorexia triggers changes in metabolism, high caloric intake may be necessary to stimulate weight gain.

Unfortunately, there is no completely effective treatment for anorexia nervosa, and recovery can take many years. Even after some weight gain, many people with anorexia remain quite thin and risk of relapse is very high. A number of influences in the social environment may make recovery difficult:

• Friends or family who express admiration or envy of the patient's thinness
• Dance instructors or athletic coaches who put a premium on having a very lean body
• Denial on the part of parents or other family members
• A patient's persistent belief that emaciation is not only normal but attractive and/or that purging is the only way to avoid becoming overweight

Soliciting the involvement of friends, family members, and others in the treatment of the individual, with education for everyone regarding the gravity of the disease, may diminish these influences.

Lifestyle

Treating anorexia nervosa involves major lifestyle changes. Not only must eating habits be altered, but the individual must adjust his or her self perception to no longer hold a distorted body image. The following lifestyle changes may help in this process:

• Establishing regular eating habits and a healthy diet
• Developing a support system and participating in a support group for help with stress and emotional issues
• Cutting back on exercise if obsessive exercise has been part of the disease. Once sufficient weight gain has been established, controlled exercise regimens can be a positive reinforcement for appropriate eating habits and a way to reduce gastrointestinal distress.

Medications

Anorexia nervosa in some ways resembles other major psychiatric disorders such as depression and obsessive-compulsive disorder, because some of the symptoms of these disorders, for example obsessive behavior, lack of enjoyment from life, and severely distorted perception of reality (in this case, of the body), are exhibited by people with anorexia. This has led to the use of antidepressants for anorexia, particularly selective serotonin reuptake inhibitors (SSRIs), because these drugs are first-line treatments for OCD and depression. Medications, however, do not work alone and must be used in conjunction with a multidisciplinary approach that includes nutritional interventions and psychotherapy.

Serotonin Reuptake Inhibitors

• Fluoxetine

Studies suggest that fluoxetine may increase weight and improve mood over several months in people with anorexia nervosa and depression. Similarly positive results were obtained in a preliminary study of anorexics whose body weight had already been partly restored.

Tricyclic Antidepressants
This class of antidepressants, including imipramine and desipramine, tend to be more effective for bulimia than anorexia.

• Clomipramine

One study suggests that clomipramine has the potential to stimulate weight gain and improve symptoms of anorexia, but more research is needed on the value of this drug in treating this particular eating disorder.

Antihistamines

• Cyproheptadine

In a study using high doses of cyproheptadine hydrochloride, which is thought to stimulate appetite, the number of days necessary to achieve appropriate weight gain were decreased and depression was relieved in those with restricting type anorexia.

Hormones
Estrogen together with progesterone may be used to restore normal menstrual cycles. This, however, does not generally have any effect on weight.

Nutrition and Dietary Supplements

Anorexics with low body weight, low BMI, and low serum albumin (the main protein in blood) levels are at increased risk for vitamin and mineral deficiency. Vitamin abnormalities may contribute to cognitive difficulties such as poor judgment or memory loss and other psychiatric conditions. These deficiencies can often be corrected with dietary interventions. Therefore, an important part of treatment is to include a multivitamin with minerals (particularly calcium).

Vitamin B Complex
Deficiencies in vitamins B2 (riboflavin) and B6 (pyridoxine) have been noted in those with anorexia, with some studies suggesting that deficiency of these B vitamins is present in approximately 20% of anorexic patients admitted to the hospital for treatment. One small study of 13 people with anorexia found 33% of the participants were deficient in vitamins B2 and B6 may be deficient in as many as 33% of those with this eating disorder. Dietary changes alone, without additional supplements, often can bring vitamin B levels back to normal.

Antioxidants
Inadequate intake of calories, protein, and micronutrients over a prolonged period of time, as seen in people with anorexia, may cause oxidative stress, particularly when coupled with excessive physical activity. Oxidative stress is a process in which certain substances in the body generated from metabolism (breakdown of tissue for energy) cause cell damage. Antioxidants, such as vitamins A, C, and E, are substances that can help protect the body from the damage of oxidative stress. In a study comparing antioxidant levels in healthy female adolescents to those with anorexia, researchers found that the anorexic group had reduced amounts of these protective substances, such as vitamin E, and that the antioxidants were not as active in the blood as they normally would be. It is unclear, however, whether supplementation with antioxidants including vitamins E and C, beta-carotene, coenzyme Q10, and selenium will correct deficiencies in people with anorexia or improve their treatment in any way. Currently, supplementation with antioxidants is not part of standard care for anorexia, but is being explored scientifically.

Zinc
Zinc influences appetite, taste, smell, vision, and cognitive function and is an essential nutrient for protein synthesis, growth, and wound healing. The symptoms of zinc deficiency include loss of appetite, weight loss, skin abnormalities, lack of menstruation, and depression. Studies have revealed that zinc deficiencies are common in those with anorexia nervosa and may contribute to a number of the symptoms of the condition.

Zinc supplementation has demonstrated the following benefits in anorexics:

• Restoring normal zinc levels
• Increasing the rate of weight gain

While zinc supplementation may be helpful as an addition to standard treatment for anorexia, there are a number of different forms of zinc and more research is needed to determine which is most effective and at what dosage.

Dehydroepiandrosterone (DHEA)
Women with anorexia nervosa are at increased risk for bone fractures and can develop osteoporosis at a younger age than women without eating disorders. It has been observed that adolescents and young adults with anorexia nervosa tend to have low levels of DHEA, a hormone produced by the adrenal glands. This is important because DHEA levels have been associated with bone mineral density, suggesting that this hormone may play a role in preventing bone loss and stimulating bone formation. Some preliminary studies suggest that women with anorexia who take 50 mg of DHEA per day are able to restore normal levels of this and other hormones, such as estrogen and testosterone, and show signs of protection from bone loss.

Essential Fatty Acids
Polyunaturated fatty acids (PUFAs), such as gamma-linolenic acid (an omega-6 fatty acid) and alpha-linolenic acid (an omega-3 fatty acid), are essential for normal growth and development. They are not made by the body and must therefore be obtained through the diet. Studies suggest that women, and possibly men, with anorexia nervosa have lower than optimal levels of PUFAs and display abnormalities in the use of these fatty acids in the body. To prevent the metabolic complications associated with essential fatty acid deficiencies, some recommend that treatment programs for anorexia nervosa include PUFA-rich foods such as organ meats and fish.

Melatonin
Melatonin is a hormone produced in the brain that regulates sleep. Studies show that fluctuations in melatonin levels may influence the symptoms of anorexia. For example, abnormally high melatonin levels may cause depressed mood and daytime sleepiness in those with anorexia. While people with restricting type of anorexia usually have normal melatonin levels, studies have found that those with binge and purge anorexia, and anorexia in combination with depression have abnormal fluctuations and levels of melatonin. Melatonin levels may play a role in the symptoms of anorexia, but it is not known whether supplementation will change the course of the disease. Some researchers speculate, however, that melatonin levels in people with anorexia may indicate who is likely to benefit from antidepressant medications.

Herbs

While the following appetite stimulants have not been studied for the treatment of anorexia nervosa, they have been used in certain traditional healing systems to stimulate appetite and may be recommended as a complementary therapy by an herbal specialist:

• Angelica root (Angelica archangelica)
• Blessed thistle herb (Cnicus benedictus)
• Gentian root (Gentiana lutea)
• Cinnamon bark (Cinnamomum verum)
• Dandelion herb and root (Taraxacum officinale)

In cases of significant weight loss where the muscles begin to deteriorate, some herbalists may recommend fenugreek seed (Trigonella foenum-graecum). Skullcap (Scutellaria lateriflora) may be used to relax the nerves and Roman chamomile (Chamaemelum nobile) may be used to treat depression associated with anorexia.

Massage and Physical Therapy

Massage appears to be a helpful component of treatment for anorexia nervosa. In one study, a group of adolescents with anorexia received massages twice weekly for one month, in addition to standard daily group therapy. The massaged adolescents reported lower anxiety levels and improved body image compared to adolescents with anorexia receiving only standard daily group therapy. Measurably reduced cortisol (a marker of stress) and increased dopamine (a brain chemical associated with relaxation) concentrations were also observed in the treatment group.

Homeopathy

A professional homeopath can provide supportive care to address various aspects of anorexia. Because of the seriousness of the condition, anorexic people are advised against treating themselves with homeopathic remedies.

Mind/Body Medicine

Cognitive Behavioral Therapy
Cognitive-behavioral therapy is reported to be one of the most effective therapies for anorexia. It is based on the assumption that anorexia develops in response to life stresses. Treatment is aimed at confronting the individual's fears and avoidance behaviors and cultivating new problem-solving skills. It also aims to increase awareness of negative thought processes and to change them. Cognitive techniques are used to encourage patients to evaluate and challenge their automatic thoughts, examine their underlying assumptions, and replace them with realistic beliefs and actions based on reasonable self-expectations.

Family Therapy
Family therapy is recommended for both children and adults, in addition to individual therapy for the person with anorexia. Parents and other family members often have intense feelings of guilt and anxiety that they need to address. They may actually support the individual's eating disorder out of these feelings or perhaps they, too, put a premium on being thin. Family therapy is aimed, in part, at helping the parents or partner (in the case of an adult) understand the medical gravity of this illness and the ways in which they may be inadvertently contributing to it.

Hypnosis
Hypnosis has been shown to be successful as part of an integrated treatment program for anorexia nervosa. Evidence suggests that purging anorexics have a greater hypnotic ability—and thus may be more likely to benefit from hypnosis—than restrictive anorexics. Hypnosis reportedly strengthens both self-confidence and the ability to cope, which may result in healthier eating, improved body image, and greater self-esteem. Whether or not the treatment is successful may depend on the number of sessions; individual programs have generally involved 1-hour per week for 3 months followed by bi-weekly sessions until treatment is no longer needed.

Biofeedback
Studies suggest that biofeedback may be helpful in reducing stress in people with anorexia.

Other Considerations

Pregnancy Anorexia poses a number of potential problems for the woman who is pregnant or wishes to become pregnant:

• Difficulty getting pregnant/carrying a pregnancy to term because of higher rates of infertility and spontaneous abortion
• Increased risk of low birth weight babies and birth defects
• Malnourishment (particularly calcium deficiency) as the fetus grows
• Increased risk of medical complications
• Increased risk of relapse being triggered from the stress of pregnancy and/or parenthood

Prognosis and Complications

Medical complications associated with anorexia include:

• Irregular heartbeat and heart attack
• Anemia, often related to lack of vitamin B12
• Low potassium, calcium, magnesium, and phosphate levels (particularly with binge-purge types)
• Increased cholesterol
• Hormonal changes (can lead to absence of menstrual periods, infertility, bone loss, and stunted growth)
• Osteoporosis
• Seizures and/or numbness in hands and feet
• Disorganized thinking
• Death (suicide is responsible for 50% of fatalities associated with anorexia)

The outlook for individuals with anorexia is variable, with recovery taking between 4 and 7 years. There is also a high chance of disease recurrence even after recovery. Long-term studies show that 50% to 70% of people recover from anorexia nervosa; however, 25% do not fully recover. Many, even after they are considered "cured," continue to exhibit traits of anorexia such as remaining very thin and striving for perfection.

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