Anorexia Nervosa

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Anorexia Nervosa

What Is It?

Anorexia nervosa is an eating disorder in which a person limits eating and weighs at least 15% less than her ideal weight. At least 90% of cases are in young women, but anorexia nervosa can occur in men. It rarely occurs before puberty or after age 40.

A person with this disorder fears being fat. She may be completely convinced that she is overweight despite what the scale shows or what other people say. To achieve or maintain leanness, she may exercise obsessively or use laxatives. Because a super-restrictive diet requires exquisite control, she may become quite careful, inhibited and controlled in other areas of life. For example, she may retreat from social contacts or may perform ritual behaviors.

The term anorexia literally means having a lack of appetite, but this is misleading because people with the disorder usually have a strong appetite or even a craving for food that they actively suppress. They diet to the point of starvation. The disorder is defined not by whether a person feels hunger but by how much weight he or she has lost.

Anorexia nervosa is most often diagnosed in industrialized societies, in which thinness is equated with attractiveness. The problem usually begins in adolescence. In girls who diet too much, the beginning of menstruation may be delayed or it may stop once it has started. Anorexia nervosa affects about 1 in 100 to 200 girls or women in the United States.

The cause of anorexia nervosa is not clear. It is likely a combination of genetic (inherited) and environmental factors. Here are some proposed causes:

• A variant of depression or anxiety — Anorexia, depression, anxiety and obsessive-compulsive disorder tend to run in families, and many people with anorexia nervosa have symptoms of depression or obsessive-compulsive disorder.

• A consequence of fears about becoming an adult — One may be fear of sexual feelings and activities that begins in adolescence. Sometimes a life event linked to normal development, such as moving away from home, triggers the illness.

• Environmental pressures — Cultural influences, including images from television and film and pressure from peers, leave the impression that thin is best. But culture is only part of the story. The illness was reported hundreds of years ago when social pressures were quite different.

• Difficult family relationships — Family difficulties can be a cause of the illness, but their importance may have been overemphasized in the past. Sometimes family problems develop after the disease has started, because a person with anorexia nervosa may test the patience of those she lives with. People with the disorder describe a feeling of power and control over others through their dieting.

In advanced stages of the illness, the dieting is hard to reverse. At that point, hunger may disappear completely and the pursuit of thinness becomes a way of life. Starvation causes medical complications of its own, such as thyroid problems, anemia [link to anemia?] and joint pains. Extreme dieting can lead to death in the most severe cases, most commonly because of an irregular heartbeat caused by an imbalance of the salts in the bloodstream.

There are two subtypes of anorexia nervosa, a restricting type and a binging/purging type. A person with the restricting type of anorexia diets, fasts and exercises. People with the binging/purging type eat large quantities of food, then vomit. Many people go back and forth between these two patterns.

Symptoms

Symptoms of anorexia nervosa include:

• Significant weight loss (more than 15% of ideal body weight)

• Extreme dieting, including skipping meals or extended fasting

• Obsessions about food and fears of eating in public

• Obsessive exercise

• Use of laxatives

• Binging and purging

• Distorted self-image; feeling fat despite being thin

• Self-esteem that depends on weight and appearance

• Amenorrhea (stopping of menstrual periods or a delay of starting menstruation in young teens)

• Skin dryness or flakiness

• Brittle nails and hair

• Anemia

• Swelling in feet and ankles

• Intolerance to cold

• Hypothermia (low body temperature)

• Poor concentration

• Dehydration

• Fainting

Diagnosis

A mental health professional, such as a psychiatrist, psychologist or social worker, can diagnose anorexia nervosa based on your history reported by the patient and the family. The person with anorexia nervosa may not report symptoms reliably, so reports from family members may be necessary to make a diagnosis. A pediatrician or primary care physician may make the diagnosis, too.

The health care professional will ask about the person's attitudes toward weight, food and body image, and will check for lower than normal body weight and the physical signs of starvation, which include:

• Low blood pressure

• Anemia

• Dry skin

• Enlarged salivary glands

• Lanugo, a very fine type of body hair

• The stopping of periods in a woman

• Dental problems because stomach acids can damage teeth if the person purges regularly)

The health care professional may use screening tests, such as the Eating Disorders Inventory and the Eating Attitudes Test.

The health care professional may explore whether the person has other problems that need treatment, such as depression, anxiety, obsessive-compulsive disorder, personality disorders or substance abuse. It is common for people with anorexia nervosa to have symptoms of depression, including low mood, social withdrawal, irritability, poor sleep and diminished interest in sex. People with the bingeing/purging type of anorexia nervosa are more likely to have mood ups and downs, have problems with impulse control, and abuse alcohol or drugs.

Medical evaluation includes blood work to investigate whether poor nutritional intake has caused anemia (low red blood cell count), altered liver and kidney function and abnormal levels of blood chemicals, such as low potassium.

A doctor also needs to make sure there are no other medical problems that might be causing weight loss, such as inflammatory bowel disease, cancer or hormonal problems. People with those illnesses do not usually have a problem with their body image.

Expected Duration

How long anorexia nervosa lasts varies. Some people have a single, relatively brief episode after experiencing an isolated stressful event. For others, the problem becomes chronic (long-lasting) and the person's condition gradually deteriorates. Many people start by restricting food, then later binge and purge. Although the majority of cases go away by late adolescence, a significant number of people have continuing problems with diet and body image into adulthood.

Prevention

There is no way to prevent anorexia nervosa. It's helpful to detect the problem as early as possible, so it's important for parents and health care professionals to be aware of the issue.

Treatment

The first goal is to make sure the person with anorexia nervosa is not in danger. Treatment should correct any problems with body fluids and salts, and doctors should make sure the heart, liver and kidneys are functioning. Hospitalization may be necessary in the most severe cases.

Behavior therapy has the best chance of helping the person move her weight into a safe range. This is especially important when the weight is dangerously low. The greatest challenge is often the patient, who cannot acknowledge the problem. Health care professionals try to define the problem in a way the person can accept, then work with the person toward common goals.

Overall, anorexia nervosa is best treated with a combination of psychotherapy and medication.

Once the person acknowledges the problem, a variety of therapy techniques can be helpful. A nutritionist can plan a healthy eating program that promotes slow weight gain. Cognitive behavior therapy encourages the person to recognize flawed thoughts about body image, food and dieting, and helps to control anxiety about eating.

Family therapy may be important, both to support and educate family members and to examine negative interactions in the family. For example, family members can be taught to avoid unproductive power struggles about food.

Later, when symptoms are under better control, the person with anorexia nervosa may want to understand the meaning of the symptoms, including how they may have affected important relationships, limited emotional growth and altered self-concept. It may also be possible to look at what underlying problems may have led to the eating disorder in the first place.

There is some evidence that antidepressant medications can help in treating anorexia. Antidepressants and other medications may be effective for people who have symptoms of depression, anxiety or obsessive-compulsive disorder. However, no medication can make a person with this disorder want to eat or gain weight.

A person's thinking about food can become distorted enough that it is considered psychotic, and in those cases, treatment may include an antipsychotic medication. Some of the newer antipsychotic drugs, such as olanzapine (Zyprexa), have a side effect that, in this case, is a benefit — weight gain.

When To Call A Professional

Contact a mental health professional, a pediatrician or a primary care physician if you have a question about food restriction, feelings of sadness or anxiety, or persistent problems with body image. A family member may be the first to notice such problems and should contact a health care professional on behalf of the person having trouble. Severe weight loss or starvation can become a medical emergency, so early treatment is desirable.

Prognosis

Many people have milder forms of anorexia nervosa and are open to treatment. These people will respond well to treatment, particularly when a variety of approaches are combined. For people who have lost a great deal of weight and have medical complications, aggressive care can reverse a downward course. There is a significant risk of death for people hospitalized for medical complications of anorexia nervosa, especially when they are very resistant to treatment. However, the majority of people with anorexia nervosa either improve significantly or have a full recovery.

Additional Info

National Association of Anorexia Nervosa and Associated Disorders P.O. Box 7 Highland Park, IL 60035 Phone: (847) 831-3438 Fax: (847) 433-4632 http://www.anad.org/

American Psychiatric Association 1400 K St., NW Washington, DC 20005 Toll-Free: (888) 357-7924 Fax: (202) 682-6850 http://www.psych.org/

American Psychological Association 750 First St., NE Washington, DC 20002-4242 Phone: (202) 336-5510 Toll-Free: (800) 374-2721 TTY: (202) 336-6123 Fax: (202) 336-5500 http://www.apa.org/

National Institute of Child Health and Human Development Building 31 Room 2A32 MSC 2425 31 Center Drive Bethesda, MD 20892-2425 Phone: (301) 496-5133 Toll-Free: (800) 370-2943 http://www.nichd.nih.gov/

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Last updated:	August 21, 2006