Anorexia nervosa

Definition

Anorexia nervosa is an eating disorder characterized by self-starvation, unrealistic fear of weight gain, and conspicuous distortion of body image.

Description

The term anorexia nervosa comes from two Latin words that mean "nervous inability to eat." Anorexics have the following characteristics in common:

• inability to maintain weight at or above what is normally expected for age or height
• intense fear of becoming fat
• distorted body image
• in females who have begun to menstruate, the absence of at least three menstrual periods in a row, a condition called amenorrhea

There are two subtypes of anorexia nervosa: a restricting type, characterized by strict dieting and exercise without binge eating; and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and/or the use of laxatives or enemas. A binge is defined as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Demographics

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It is, however, a growing problem in the early 2000s among adolescent females. Its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder and not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5 percent and 1 percent of Caucasian female adolescents. Over 90 percent of patients diagnosed with the disorder as of 2001 are female. The peak age range for onset of the disorder is 14 to 18 years. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is as of 2004 also changing. Studies indicate that anorexia is increasingly common among females of all races and social classes in the United States.

Causes and symptoms

While the precise cause of the disease is not known, anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors.

Social influences

The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper-class status as well as of female beauty. In addition, the increase in cases of anorexia includes "copycat" behavior, with some patients developing the disorder from imitating other girls.

The onset of anorexia in adolescence is attributed to a developmental crisis caused by girls' changing bodies coupled with society's overemphasis on female appearance. The increasing influence of the mass media in spreading and reinforcing gender stereotypes has also been noted.

Occupational goals

The risk of developing anorexia is higher among adolescents preparing for careers that require attention to weight and/or appearance. These high-risk groups include dancers, fashion models, professional athletes (including gymnasts, skaters, long-distance runners, and jockeys), and actresses.

Genetic and biological influences

Girls whose biological mothers or sisters have or have had anorexia nervosa appear to be at increased risk of developing the disorder.

Psychological factors

A number of theories have been advanced to explain the psychological aspects of the disorder. No single explanation covers all cases. Anorexia nervosa has been given the following interpretations:

• Overemphasis on control, autonomy, and independence: Some anorexics come from achievement-oriented families that stress physical fitness and dieting. Many anorexics are perfectionists who are driven about schoolwork and other matters in addition to weight control.
• Evidence of family dysfunction: In some families, a daughter's eating disorder serves as a distraction from marital discord or other family tensions.
• A rejection of female sexual maturity: This rejection is variously interpreted as a desire to remain a child or as a desire to resemble males.
• A reaction to sexual abuse or assault.
• A desire to appear as fragile and nonthreatening as possible: This hypothesis reflects the idea that female passivity and weakness are attractive to males.
• Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Male anorexics

Although anorexia nervosa largely affects females, its incidence in the male population is rising in the early 2000s. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals and increasing media emphasis on external appearance in men. Homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard attractive weight for heterosexual males.

When to call the doctor

A healthcare professional should be contacted if a child or adolescent is suspected of having anorexia nervosa or displays early signs of the disorder, such as the following:

• fear of gaining weight
• distorted body image
• recent weight loss
• restrictive or abnormal eating patterns such as skipping meals or eliminating once-liked foods
• preoccupation with food and dieting
• compulsive exercising
• purging behaviors such as vomiting or using laxatives
• withdrawal from friends and family
• wearing baggy clothes to hide weight loss

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Many anorexics deny that they are ill and are usually brought to treatment by a family member.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation , stomach rupture, swelling of the salivary glands, anemia and other abnormalities of the blood, loss of kidney function, and osteoporosis.

Most anorexics are diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea in female patients, and sometimes of abdominal pain , constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been self-inducing vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15 percent below normal, with some allowance for body build and weight history.

The doctor will need to rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia , social phobia, obsessive-compulsive disorder , and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Treatment of anorexia nervosa includes both short- and long-term measures and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out a treatment plan.

Hospital treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

• weight of 40 percent or more below normal or weight loss over a three-month period of more than 30 lbs (13.6 kg)
• severely disturbed metabolism
• severe binging and purging
• signs of psychosis
• severe depression or risk of suicide
• family in crisis

Hospital treatment includes individual and group therapy as well as refeeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or into a vein (hyperalimentation).

Outpatient treatment

Anorexics who are not severely malnourished can be treated by outpatient psychotherapy. The types of treatment recommended are supportive rather than insight-oriented and include behavioral approaches as well as individual or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups are often useful in helping anorexics find social support and encouragement. Psychotherapy with anorexics is a slow and difficult process; about 50 percent of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorexics have been treated with a variety of medications, including antidepressants , antianxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. The effectiveness of medications in treatment regimens is as of 2004 debated. However, at least one study of fluoxetine (Prozac) showed it helped the patient maintain weight gained while in the hospital.

Nutritional concerns

A key focus of treatment for anorexia nervosa is teaching the principles of healthy eating and improving disordered eating behaviors. A dietician or nutritionist plays an important role in forming a nutrition plan for the patient; such plans are individualized and ensure that the patient is consuming enough food to gain or maintain weight as needed and stabilize medically. The anorexic's weight and food intake are closely monitored to ensure that the plan is being followed.

Prognosis

Figures for long-term recovery vary from study to study, but reliable estimates are that 40 to 60 percent of anorexics make a good physical and social recovery, and 75 percent gain weight. The long-term mortality rate for anorexia is estimated at around 10 percent, although some studies give a lower figure of 3 to 4 percent. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families. Early treatment such as counseling may help to prevent early signs of disordered eating from progressing into more serious behaviors.

Parental concerns

There are many strategies that parents can undertake to help encourage healthy attitudes toward weight, food, and exercise in their children. These include the following:

• teaching children the importance of healthy eating and exercise
• avoiding using food as a punishment or reward
• instilling healthy eating and exercise habits by example
• being a good role model by promoting healthy body image and encouraging children and adolescents to find role models in the media who do the same
• encouraging children or teens who wish to diet to talk to a healthcare professional about healthy strategies to lose weight

KEY TERMS

Amenorrhea —The absence or abnormal stoppage of menstrual periods.

Binge —A pattern of eating marked by episodes of rapid consumption of large amounts of food; usually food that is high in calories.

Body dysmorphic disorder —A psychiatric disorder marked by preoccupation with an imagined physical defect.

Hyperalimentation —A method of refeeding anorexics by infusing liquid nutrients and electrolytes directly into central veins through a catheter.

Lanugo —A soft, downy body hair that covers a normal fetus beginning in the fifth month and usually shed by the ninth month. Also refers to the fine, soft hair that develops on the chest and arms of anorexic women. Also called vellus hair.

Purging —The use of vomiting, diuretics, or laxatives to clear the stomach and intestines after a binge.

Russell's sign —A scraped or raw area on the patient's knuckles, caused by self-induced vomiting.

Superior mesenteric artery syndrome —A condition in which a person vomits after meals due to blockage of the blood supply to the intestine.

See also Binge eating disorder; Bulimia nervosa.

Resources

BOOKS

"Anorexia Nervosa." In The Merck Manual of Diagnosis and Therapy, 17th ed. Edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck & Co. Inc., 2004.

Knowles, Jarol B. "Eating Disorders." In Textbook of Primary Care Medicine, 3rd ed. Edited by John Noble. St. Louis: Mosby Inc., 2001.

Litt, Iris F. "Anorexia Nervosa and Bulimia." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman, Robert M. Kliegman, and Hal B. Jenson. Philadelphia: Saunders, 2004.

Smith, Delia. "The Eating Disorders." In Cecil Textbook of Medicine, 21st ed. Edited by Lee Goldman and J. Claude Bennett. Philadelphia: Saunders, 2000.

PERIODICALS

American Academy of Pediatrics Committee on Adolescence. "Identifying and Treating Eating Disorders." Pediatrics 111, no. 1 (January 1, 2003): 204–11.

Pritts, Sarah D., and Jeffrey Susman. "Diagnosis of Eating Disorders in Primary Care." American Family Physician 67, no. 2 (January 15, 2003): 297–304.

Rome, E. S. "Eating Disorders." Obstetrics and Gynecology Clinics of North America 30, no. 2 (June 1, 2003): 353–77.

Rosen, David S. "Eating Disorders in Children and Young Adolescents: Etiology, Classification, Clinical Features, and Treatment." Adolescent Medicine 14, no. 1 (February 1, 2003): 49–59.

——. "Eating Disorders in Adolescent Males." Adolescent Medicine 14, no. 3 (October 1, 2003): 677–89.

Sigman, Gary S. "Eating Disorders in Children and Adolescents." Pediatric Clinics of North America 50, no. 5 (October 2003): 1139–77.

ORGANIZATIONS

American Anorexia/Bulimia Association. 418 East 76th St., New York, NY 10021. Telephone: 212/734–1114.

National Association of Anorexia Nervosa and Associated Disorders. Web site: <www.anad.org>.

National Institute of Mental Health Eating Disorders Program. Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. Telephone: 301/496–1891.

Rebecca J. Frey, PhD Stephanie Dionne Sherk

Anorexia Nervosa

Definition

Anorexia nervosa is an eating disorder characterized by unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. The name comes from two Latin words that mean nervous inability to eat. In females who have begun to menstruate, anorexia nervosa is usually marked by amenorrhea, or skipping at least three menstrual periods in a row. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV (1994), defines two subtypes of anorexia nervosa-a restricting type, characterized by strict dieting and exercise without binge eating; and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas. DSM-IV defines a binge as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Description

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of DSM in 1980. It is, however, a growing problem among adolescent females. Its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder, and not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5-1% of caucasian female adolescents. Over 90% of patients diagnosed with the disorder as of 1998 are female. It was originally thought that only 5% of anorexics are male, but that estimate is being revised upward. The peak age range for onset of the disorder is 14-18 years, although there are patients who develop anorexia as late as their 40s. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is also changing. More recent studies indicate that anorexia is increasingly common among women of all races and social classes in the United States.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation, stomach rupture, swelling of the salivary glands, anemia and other abnormalities of the blood, loss of kidney function, and osteoporosis.

Causes and symptoms

Anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors. While the precise cause of the disease is not known, it has been linked to the following:

Social influences

The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper-class status as well as of female beauty. In addition, the increase in cases of anorexia includes "copycat" behavior, with some patients developing the disorder from imitating other girls.

The onset of anorexia in adolescence is attributed to a developmental crisis caused by girls' changing bodies coupled with society's overemphasis on women's looks. The increasing influence of the mass media in spreading and reinforcing gender stereotypes has also been noted.

Occupational goals

The risk of developing anorexia is higher among adolescents preparing for careers that require attention to weight and/or appearance. These high-risk groups include dancers, fashion models, professional athletes (including gymnasts, skaters, long-distance runners, and jockeys), and actresses.

KEY TERMS

Amenorrhea— Absence of the menses in a female who has begun to have menstrual periods.

Binge eating— A pattern of eating marked by episodes of rapid consumption of large amounts of food; usually food that is high in calories.

Body dysmorphic disorder— A psychiatric disorder marked by preoccupation with an imagined physical defect.

Hyperalimentation— A method of refeeding anorexics by infusing liquid nutrients and electrolytes directly into central veins through a catheter.

Lanugo— A soft, downy body hair that develops on the chest and arms of anorexic women.

Purging— The use of vomiting, diuretics, or laxatives to clear the stomach and intestines after a binge.

Russell's sign— Scraped or raw areas on the patient's knuckles, caused by self-induced vomiting.

Superior mesenteric artery syndrome— A condition in which a person vomits after meals due to blockage of the blood supply to the intestine.

Genetic and biological influences

Women whose biological mothers or sisters have the disorder appear to be at increased risk.

Psychological factors

A number of theories have been advanced to explain the psychological aspects of the disorder. No single explanation covers all cases. Anorexia nervosa has been interpreted as:

• A rejection of female sexual maturity. This rejection is variously interpreted as a desire to remain a child, or as a desire to resemble men as closely as possible.
• A reaction to sexual abuse or assault.
• A desire to appear as fragile and nonthreatening as possible. This hypothesis reflects the idea that female passivity and weakness are attractive to men.
• Overemphasis on control, autonomy, and independence. Some anorexics come from achievement-oriented families that stress physical fitness and dieting. Many anorexics are perfectionistic and "driven" about schoolwork and other matters in addition to weight control.
• Evidence of family dysfunction. In some families, a daughter's eating disorder serves as a distraction from marital discord or other family tensions.
• Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Male anorexics

Although anorexia nervosa is still considered a disorder that largely affects women, its incidence in the male population is rising. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals and increasing media emphasis on external appearance in men. Moreover, homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard "attractive" weight for heterosexual males.

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Most anorexics deny that they are ill and are usually brought to treatment by a family member.

Most anorexics are diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea (failure to menstruate) in females, and sometimes of abdominal pain, constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15% below normal, with some allowance for body build and weight history.

The doctor will need to rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test ) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Treatment of anorexia nervosa includes both short- and long-term measures, and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out treatment plan.

Hospital treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

• weight of 40% or more below normal; or weight loss over a three-month period of more than 30 pounds
• severely disturbed metabolism
• severe binging and purging
• signs of psychosis
• severe depression or risk of suicide
• family in crisis

Hospital treatment includes individual and group therapy as well as refeeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or by overfeeding (hyperalimentation techniques).

Outpatient treatment

Anorexics who are not severely malnourished can be treated by outpatient psychotherapy. The types of treatment recommended are supportive rather than insight-oriented, and include behavioral approaches as well as individual or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups are often useful in helping anorexics find social support and encouragement. Psychotherapy with anorexics is a slow and difficult process; about 50% of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorexics have been treated with a variety of medications, including antidepressants, antianxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. The effectiveness of medications in treatment regimens is still debated. However, at least one study of Prozac showed it helped the patient maintain weight gained while in the hospital.

Prognosis

Figures for long-term recovery vary from study to study, but the most reliable estimates are that 40-60% of anorexics will make a good physical and social recovery, and 75% will gain weight. The long-term mortality rate for anorexia is estimated at around 10%, although some studies give a lower figure of 3-4%. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families.

Resources

BOOKS

Baron, Robert B. "Nutrition." In Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.

ORGANIZATIONS

American Anorexia/Bulimia Association. 418 East 76th St., New York, NY 10021. (212) 734-1114.

National Institute of Mental Health Eating Disorders Program. Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-1891.

Anorexia nervosa

Definition

Anorexia nervosa (AN) is an eating disorder characterized by an intense fear of gaining weight and becoming fat. Because of this fear, the affected individual starves herself or himself, and the person's weight falls to about 85% (or less) of the normal weight for age and height.

Description

AN affects females more commonly than males—90% of those affected are female. Typically, the disorder begins when an adolescent or young woman of normal or slightly overweight stature decides to diet. As weight falls, the intensity and obsession with dieting increases. Affected individuals may also increase physical exertion or exercise as weight decreases to lose more pounds. An affected person develops peculiar rules concerning exercise and eating. Weight loss and avoidance of food is equated in these patients with a sense of accomplishment and success. Weight gain is viewed as a sign of weakness (succumbing to eat food) and as failure. Eventually, the affected person becomes increasingly focused on losing weight and devotes most efforts to dieting and exercise.

Anorexia nervosa is a complex eating disorder that has biological, psychological, and social consequences for those who suffer from it. When diagnosed early, the prognosis for AN is good.

Causes and symptoms

Causes

The exact causes of AN are not currently known, but the current thinking about AN is that it is caused by multiple factors. There are several models that can identify risk factors and psychological conditions that predispose people to develop AN. The predisposing risk factors include:

• female gender
• perfectionism
• personality factors, including being eager to please other people and high expectations for oneself
• family history of eating disorders
• living in an industrialized society
• difficulty communicating negative emotions such as anger or fear
• difficulty resolving problems or conflict
• low self-esteem

Specialists in family therapy have demonstrated that dysfunctional family relationships and impaired family interaction can contribute to the development of AN. Mothers of persons with AN tend to be intrusive, perfectionistic, overprotective, and have a fear of separation. Fathers of AN-affected individuals are often described as passive, withdrawn, moody, emotionally constricted, obsessional, and ineffective. Sociocultural factors include the messages given by society and the culture about women's roles and the thinness ideal for women's bodies. Developmental causes can include adolescent "acting out" or fear of adulthood transition. In addition, there appears to be a genetic correlation since AN occurs more commonly in biological relatives of persons who have this disorder.

Precipitating factors are often related to the developmental transitions common in adolescence. The onset of menarche (first menstrual cycle) may be threatening in that it represents maturation or growing up. During this time in development, females gain weight as part of the developmental process, and this gain may cause a decrease in self-esteem. Development of AN could be a way that the adolescent retreats back to childhood so as not to be burdened by maturity and physical concerns. Autonomy and independence struggles during adolescence may be acted out by developing AN. Some adolescents may develop AN because of their ambivalence about adulthood or because of loneliness, isolation, and abandonment they feel.

Symptoms

Most of the physical symptoms associated with AN are secondary to starvation. The brain is affected— there is evidence to suggest alterations in brain size, neurotransmitter balance, and hormonal secretion signals originating from the brain. Neurotransmitters are the chemicals in the brain that transmit messages from nerve cell to nerve cell. Hormonal secretion signals modulate sex organ activity. Thus, when these signals are not functioning properly, the sex organs are affected. Significant weight loss (and loss in body fat, in particular) inhibits the production of estrogen, which is necessary for menstruation. AN patients experience a loss of menstrual periods, known as amenorrhea. Additionally, other physiologic systems are affected by the starvation. AN patients often suffer from electrolyte (sodium and potassium ion) imbalance and blood cell abnormalities affecting both white and red blood cells. Heart function is also compromised and a person affected with AN may develop congestive heart failure (a chronic weakening of the heart due to work overload), slow heart rate (bradycardia), and abnormal rates and rhythms (arrhythmias). The gastrointestinal tract is also affected, and a person with AN usually exhibits diminished gastric motility (movement) and delayed gastric emptying. These abnormalities may cause symptoms of bloating and constipation. In addition, bone growth is affected by starvation, and over the long term, AN patients can develop osteoporosis, a bone loss disease.

Physically, people with AN can exhibit cold hands and feet, dry skin, hair loss, headaches, fainting, dizziness, and lethargy (loss of energy). Individuals with AN may also develop lanugo (a fine downy hair normally seen in infants) on the face or back. Psychologically, these people may have an inability to concentrate, due to the problems with cognitive functioning caused by starvation. Additionally, they may be irritable, depressed, and socially withdrawn, and they obsessively avoid food. People affected with AN may also suffer from lowered body temperature (hypothermia), and lowered blood pressure, heart rate, glucose and white blood cells (cells that help fight against infection). They may also have a loss of muscle mass.

In order to diagnose AN, a patient's symptoms must meet the symptom criteria established in the professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders , also called the DSM. These symptoms include:

• Refusal to maintain normal body weight, resulting in a weight that is less than 85% of the expected weight.
• Even though the affected person is underweight, he or she has an intense fear of gaining weight.
• Distorted body image, obsession with body weight as key factor in self-evaluation, or denial of the seriousness of the low body weight.
• Amenorrhea.

Demographics

AN is considered to be a rare illness. The prevalence even in high-risk groups and high-risk situations is approximately 0.5%–1%. Partial disorders (diagnosed when symptoms are present, but do not meet the full criteria as established in the DSM ) are more commonly seen in psychological practice. The incidence (number of new cases) of AN has increased during the last 50 years due to increased societal concerns regarding body shape, weight, and appearance. Some occupations such as ballet dancing and fashion modeling may predispose persons to develop AN, due to preoccupation with physical appearance. This disorder usually affects women more than men in a ratio of between one to 20 and one to 10.

Diagnosis

Initial assessment usually includes a careful interview and history (clinical evaluation). A weight history, menstrual history, and description of daily food intake are important during initial evaluation. Risk factors and family history are also vital in suspected cases. Laboratory results can reveal anemia (low red blood cell count in the blood), lowered white blood cells, pulse, blood pressure, and body temperature. The decreased temperature in extremities may cause a slight red-purple discoloration in limbs (acrocynanosis). There are two psychological questionnaires that can be administered to aid in diagnosis , called the Eating Attitudes Test (EAT) and Eating Disorders Inventory (EDI). The disadvantage of these tests is that they may produce false-positive results, which means that a test result may indicate that the test taker has anorexia, when, actually, s/he does not.

Treatments

People affected with AN are often in denial, in that they don't see themselves as thin or in need of professional help. Education is important, as is engagement on the part of the patient—a connection from the patient to her treatment, so that she agrees to be actively involved. Engagement is a necessary but difficult task in the treatment of AN. If the affected person's medical condition has deteriorated, hospitalization may be required. Initially, treatment objectives are focused on reversing behavioral abnormalities and nutritional deficiencies. Emotional support and reassurance that eating and caloric restoration will not make the person overweight, are essential components during initial treatment sessions. Psychosocial (both psychological and social) issues and family dysfunction are also addressed, which may reduce the risk of relapsing behaviors. (Relapsing behaviors occur when an individual goes back to the old patterns that he or she is trying to eliminate.) At present, there is no standardized psychotherapeutic treatment model to address the multifactorial problems associated with AN. Cognitive-behavioral therapy (CBT) may help to improve and modify irrational perceptions and overemphasis of weight gain. Current treatment usually begins with behavioral interventions and should include family therapy (if age appropriate). Psychodynamic psychotherapy (also called exploratory psychotherapy ) is often helpful in the treatment of AN. There are no medications to treat AN. Treatment for this disorder is often long term.

Prognosis

If this disorder is not successfully diagnosed or treated, the affected person may die of malnutrition and multi-organ complications. However, early diagnosis and appropriate treatment interventions are correlated with a favorable outcome.

Research results concerning outcome of specific AN treatments are inconsistent. Some results, however, have been validated. The prognosis appears to be more positive for persons who are young at onset of the disorder, and/or who have experienced a low number of disorder related hospitalizations. The prognosis is not as positive for people with long duration illness, very low body weight, and persistent family dysfunction. Additionally, the clinical outcome can be complicated by comorbid, or co-occurring or concurrent, disorders (without any causal relationship to AN) such as depression, anxiety, and substance abuse.

Prevention

A nurturing and healthy family environment during developing years is particularly important. Recognition of the clinical signs with immediate treatment can possibly prevent disorder progression, and, as stated, early diagnosis and treatment are correlated with a favorable outcome.

See also Bibliotherapy

Resources

BOOKS

Tasman, Allan, and others, eds. Psychiatry., 1st ed. Philadelphia: W. B. Saunders Company, 1997.

PERIODICALS

Kreipe, R. E. "Eating disorders in adolescents and young adults." Medical Clinics of North America 84, no. 4 (July 2000).

Powers, P., and C. Santana. "Women's mental health." Primary Care: Clinics in Office Practice 29, no. 1 (March 2002).

Powers, P. "Eating Disorders: Initial assessment and early treatment options for anorexia nervosa and bulimia nervosa." Psychiatric Clinics of North America 19, no. 4 (December 1996).

ORGANIZATIONS

National Association of Anorexia Nervosa and Associated Disorders. PO Box 7, Highland Park, Il 60035. Hotline: (847) 831-3438. <http://www.anad.org>.

Laith Farid Gulli, M.D. Catherine Seeley, CSW Nicole Mallory, MS, PA-C

Anorexia

Definition

Anorexia is characterized by a loss of appetite or lack of desire to eat.

Description

Anorexia is common in cancer patients with reported incidence between 15% and 40%. Primary anorexia is especially prevalent in patients with advanced malignancy, and is frequently a side effect of cancer treatments. Sometimes, early symptoms may remain undiagnosed, or will be masked by a more generalized wasting of the body from chronic disease, known as cachexia.

When patients experience appetite loss, decreased energy consumption will subsequently lead to weight loss . When inadequate calories are consumed, the body may become weaker and less able to tolerate cancer therapies. As body weight decreases, cachexia sets in, and a general failure to thrive may make it more difficult to fight off illness and infection. A poor response to cancer treatments, reduced quality of life, and death may result from substantial weight loss. The spiraling effect of a patient's reluctance to eat is a source of frequent anxiety for caregivers. Weight loss due to anorexia may be temporary or may continue at a life-threatening pace if the patient continues to consume inadequate energy to sustain bodyweight.

Causes

It is normal for a patient to consume less energy when not as active. It is also natural to lose interest in food when individuals are seriously ill. However, it is essential in anorexic patients to consider whether the loss of appetite is the result of a natural disinterest in eating (primary anorexia), or is due to some reversible cause (secondary anorexia).

Secondary anorexia may be a result of:

• nausea with or without fear of vomiting after food consumption
• fatigue
• constipation
• sores in the mouth or mouth pain
• candidiasis
• unappetizing food or change in food preference due to cancer-related treatments
• depression
• odors in the environment, or heightened sensitivity to odors as a result of cancer-related treatments
• early satiation
• metabolic causes such as hypercalcemia and uremia
• radiation therapy or chemotherapy
• drugs such as antibiotics or drugs that can cause nausea

Special concerns

In order to allow normal tissue repair following aggressive cancer therapies, patients require adequate energy and macronutrients in the form of protein, carbohydrates, and fat. Inadequate consumption of food and/or poor nutrition may impair the ability of a patient to tolerate a specific therapy. If a low tolerance to therapy necessitates a decrease in dose, the therapy's effectiveness could be compromised. Wound healing may also be impaired with poor nutrition and inadequate energy intake.

Individuals who experience pain, nausea, or diarrhea due to the side effects of radiation and chemotherapy may want to discuss treatments options with their doctor to ease these side effects.

Treatments

Dietary tips for managing anorexia

• Serve food when the patient is hungry. A microwave oven often helps.
• Have the patient eat small meals every one to two hours, or time meals corresponding to when the patient feels best (typically early in the day).
• If only a little food is consumed by the patient, it should ideally be high in protein and calories. Avoid empty calories (i.e. foods without protein and nutrients).
• Add extra calories and protein to foods with the use of butter, skim milk powder, commercially prepared protein powder, honey, or brown sugar.
• Try to tempt the patient with tiny portions on small plates.
• Serve food in an attractive manner.
• Food is more likely to be eaten if it is served at frequent intervals unrelated to standard meal times.
• Avoid strong aromas if the patient finds them bothersome.
• Avoid liquids with meals to decrease problems of early satiety
• A small alcoholic drink of the patient's choice may help unless contraindicated.
• Consider flavors, consistency and quantity of food when preparing meals.
• Encourage eating with friends or family members; a meal in a social setting may help the patient to eat.
• Stimulate appetite with light exercise.
• Treat any underlying cause and, if a particular drug appears to be the cause, modify drug regimen.
• Have the patient take medications with high-calories fluids, i.e. commercial liquid supplements unless medication necessitates an empty stomach.

Often, patients may experience difficulty with eating due to upper gastrointestinal blockage such as problems with swallowing, esophageal narrowing, tumor, stomach weakness, paralysis, or other conditions that preclude normal food intake. In those circumstances, enteral nutrition may be administered through a tube into the gastrointestinal tract via the nose, or through surgically placed tubes into the stomach or intestines. If the gastrointestinal tract is working and will not be affected by the cancer treatments, then enteral support by feeding directly into the gut is preferable. Parenteral nutrition (most often an infusion into a vein) can be used if the gut is not functioning properly or if there are other reasons that prevent enteral feeding.

An appetite stimulant may be given such as megestrol acetate or dexamethasone . In clinical trials , both these medications appear to have similar and effective appetite stimulating effects with megestrol acetate having a slightly better toxicity profile. Fluoxymesterone has shown inferior efficacy and an unfavorable toxicity profile.

Alternative and complementary therapies

Depression may affect approximately 15-25% of cancer patients, particularly if the prognosis for recovery is poor. If anorexia is due to depression, there are antidepressant choices available through a physician. Counseling may be also be sought through a psychologist or psychiatrist to deal with depression.

St. John's Wort has been used as a herbal remedy for treatment of depression, but it and prescription antidepressants is a dangerous combination that may cause symptoms such as nausea, weakness, and may cause one to become incoherent. It is important to check with a dietitian or doctor before taking nutritional supplements or alternative therapies because they may interfere with cancer medications or treatments.

Resources

BOOKS

Keane, Maureen et al. What to Eat If You Have Cancer: A Guide to Adding Nutritional Therapy to Your Treatment Plan. Lincolnwood, IL: National Textbook Company/Contemporary Publishing Group, 1996.

Nixon, Daniel W., M.D., Jane A. Zanca, and Vincent T. DeVita, The Cancer Recovery Eating Plan: The Right Foods to Help Fuel Your Recovery. New York:Times Books, 1996.

Quillin, Patrick and Noreen Quillin. Beating Cancer With Nutrition-Revised. Sun Lakes, AZ: Bookworld Services, 2001.

PERIODICALS

Kant, Ashima et al. "A Prospective Study of Diet Quality and Mortality in Women." JAMA 283 (16) (2000): 2109-2115.

Loprinzi, C.L. et al. "Randomized comparison of megestrol acetate versus dexamethasone versus fluoxymesterone for the treatment of cancer anorexia/cachexia." Journal of Clinical Oncology 17 (10) (1999): 3299-306.

Singletary, Keith. "Diet, Natural Products and Cancer Chemoprevention." Journal of Nutrition 130 (2000): 465S-466S.

Willett, Walter C. "Diet and cancer." The Oncologist 5(5)(2000): 393-404.

ORGANIZATIONS

National Center for Complementary and Alternative Medicine (NCCAM), 31 Center Dr., Room #5B-58, Bethesda, MD 20892-2182. (800) NIH-NCAM, Fax (301) 495-4957. <http://nccam.nih.gov>.

The National Cancer Institute (NCI). For information contact the Public Inquiries Office: Building, 31, Room 10A31, 31 Center Drive, MSC 2580, Betheseda, MD 20892-2580 USA. (301) 435-3848, 1-800-4-CANCER. <http://cancer.gov/publications>, <http://cancernet.nci.nih.gov>.

American Institute for Cancer Research, 1759 R Street N.W., Washington, D.C. 20009. (800) 843-8114 or (202) 328-7744. <http://www.aicr.org, e-mail:support@aicr.org>.

Crystal Heather Kaczkowski, MSc.

KEY TERMS

Anorexia

—A condition frequently observed in cancer patients characterized by a loss of appetite or desire to eat.

Cancer

—A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread through the bloodstream and lymphatic system to other parts of the body.

Candidiasis

—A yeast-like fungal infection occuring on the skin or mucous membranes, i.e. mouth.

Chemotherapy

—Chemotherapy kills cancer cells using drugs taken orally or by needle in a vein or muscle. It is referred to as a systemic treatment due to fact that it travels through the bloodstream and kills cancer cells outside the small intestine.

Hypercalcemia

—A high calcium blood concentration above 10.5 milligrams per deciliter of blood. Increased gastrointestinal tract absorption or increased intake of calcium may lead to hypercalcemia.

Malignant (also malignancy)

—Meaning cancerous; a tumor or growth that often destroys surrounding tissue and spreads to other parts of the body.

Radiation therapy

—Also called radiotherapy; uses high-energy x-rays to kill cancer cells.

Satiation

—A feeling of fullness or satisfaction during or after food intake.

Uremia

—An excess of nitrogenous substances in the blood that are toxic and usually excreted by the kidneys.

ANOREXIA NERVOSA

The term "anorexia nervosa" was coined by William Gull in 1873. Although the term has existed for little more than a century, the clinical description of the syndrome is much older. Among other works, we can find a description in Avicenna in the eleventh century, and we have no difficulty recognizing it in Richard Morton's 1694 account of "nervous consumption." The first complete description in terms identical to those of Gull can be found in an article written by Dr. Louis Victor Marcé in 1860.

The classic clinical picture of anorexia brings together three factors: weight loss of more than 10 percent, amenorrhea, and the absence of a manifest melancholic or delusional mental disturbance. But the emphasis has changed from these classic symptoms to more specific symptoms, such as a confused body image, denial of being thin, desperate desire to be thin, and fear of putting on weight. Also, two major types of anorexia nervosa have been distinguished: purely restrictive forms and forms associated with bulimic episodes accompanied by weight monitoring, self-induced vomiting, and excessive use of laxatives and diuretics. Anorexia nervosa frequently occurs during adolescence, especially among females (ten girls for every one boy). It affects between 1 and 2 percent of the female adolescent population.

Without ever dealing specifically with eating disorders, Freud did in fact establish all of the perspectives—hysteria, melancholia, and "actual" neurosis—around which the pathological manifestations of anorexia can be understood metapsychologically. As a hysteria, anorexia involves a double polarity: oral fixations of the libido serve as a point of regression, and sexual fantasies become oral and are then repressed. As a melancholia, anorexia involves melancholy over the issue of object loss and a loss of instinctual needs. Freud speaks of an anesthesia that leads to melancholic thinking, which opens up a research path related to the next perspective. As an "actual" neurosis, anorexia poses a threefold question about the importance of the current situation, of somatic and infrarepresentational factors, and of the inadequacy of the ego and capacities for working matters out.

Melanie Klein and her students have stressed the importance of archaic fantasies of sadistic devouring, destruction, and poisoning in anorexia. Psychoanalysts dealing specifically with eating disorders initially considered them to be primarily a symptom and took little interest in the organization of the personality. But because of the complexity of cases and the frequent severity of the evolution of the disorder, the pathology of the personality assumed a growing importance in their work. The Göttingen symposium, organized by J. E. Meyer and H. Feldmann (1965), recognized anorexia nervosa as having a specific structure and viewed it not so much as an attempt toward compromise formation but rather as an attempt to deal with psychotic failures in the organization of the ego by reestablishing the mother-child unit.

Evelyne Kestemberg et al. (1974) have provided a remarkable description of the specific modes of the regression and instinctual organization in anorexia. This organization is characterized by recourse to a primary erogenous masochism in which pleasure is linked directly to a refusal to satisfy a need. Pleasure does not accompany the feeling of having something inside oneself; rather, anorexia eroticizes not satisfying a vital need. Similarly, relationships become dominated by pleasure in their being not satisfied. The hedonization of refusal becomes the guardian of the feeling of being or existing in one's own right, corporeal activity and the body being thus liberated from all external holds. The most complete form of this hedonization of refusal is "hunger orgasm."

Different studies stress the importance of the dependence/autonomy conflict and the fundamental vulnerability of anorexics. This vulnerability is associated with powerful passive desires and, as a consequence, a constant fear of intrusion, particularly an invasion of the body by the object on which these desires depend. To pose the problem in terms that highlight the paradox of anorexia: anorexics destroy themselves to prove their own existence. The destructive effect is not sought after for its own sake, and in this respect anorexia is not a suicidal behavior, although it can be seen as the result of unleashing aggression and turning against the self an incorporation fantasy of an object experienced as destructive for the self. Anorexia is the consequence of using a physiological need indispensable for survival to preserve a feeling of autonomy. In doing so—and this is the second paradox—anorexics find themselves in fact more dependent on an environment from which they sought to free themselves. By making refusal the instrument of their liberation, they alienate themselves from the object of the refusal, which they can neither lose nor interiorize.

The anorexia-bulimia tandem leads to questions about whether a problem of dependence underlies other behaviors grouped under the label "addictive behaviors": drug addiction, alcoholism, pathological gambling, and shopping, as well as abuse of psychotropic drugs and kleptomania. The fragile narcissistic bases of such addicts makes their object relations difficult to manage, because these object relations become too exciting and too dangerous. Addiction to products or behavioral practices offers addicts a need-satisfying relational substitute that is always accessible and which they believe they can control, while in fact they fall into its grip.

The eating disorder represents a substitute for the object whose loss could plunge these patients into a collapse. This attempt to find a substitute object in addictive behavior represents a perverse organization of a relationship to the object in which the object is not recognized as having its own desires and differences, but is acknowledged only for purposes of narcissistic reassurance. An analogy exists among these patients' relationship with food, their relationship with their own bodies, and their object relations, as well as their modes of emotional investment in general.

Family-therapy approaches illustrate the sensitivity of these patients to the influences of their environment. These eating disorders can be seen as existing at an intersection between individual psychology, family interactions, the body in its most biological aspect, and society in general. An essentially mental disorder may thus have grave somatic consequences, and these consequences may in turn affect the anorexic's psychic state and thus contribute to maintaining the disorder.

Addictive behaviors raise questions about the type of society in which we live, particularly with the increase in the frequency of these disorders accompanying the increase in consumerism in our societies.

Philippe Jeammet

See also: Adolescence; Autistic capsule/nucleus; Bulimia; Flower Doll: Essays in Child Psychotherapy ; Kestemberg-Hassin, Evelyne.

Bibliography

Agman, Gilles; Corcos, Maurice; and Jeammet, Philippe. (1994). Troubles des conduits alimentaires. In Encyclopédie medico-chirurgicale (Psychiatrie vol., fasc. 37-350-A-10). Paris: Encyclopédie medico-chirurgicale.

Brusset, Bernard. (1998). Psychopathologie de l'anorexie mentale. Paris: Dunod.

Kestemberg, Evelyne; Kestenberg, Jean; and Decobert, Simone. (1972). La faim et le corps: une étude psychanalytique de l'anorexie mentale. Paris: Presses Universitaires de France.

Venisse, Jean-Luc (Ed.). (1991). Les nouvelles addictions. Paris: Masson.

Further Reading

Aronson, Joyce K. (ed.) (1993). Insights in the dynamic psychotherapy of anorexia and bulimia: An introduction to the literature. Northvale, NJ: Jason Aronson.

Freedman, Norbert, et. al. (2002). Desymbolization: concept & observations on anorexia & bulimia. Psychoanalysis and Contemporary Thought, 25,165-200.

Sours, John. (1980). Starving to death in a sea of objects: the anorexia nervosa syndrome. New York: Jason Aronson.

Thoma, Helmut. (1967). Anorexia nervosa. New York: International Universities Press.

Wilson, Charles, Hogan, C., and Mintz, Ira. (1985). Fear of being fat: the treatment of anorexia and bulimia (2nd ed). Northvale, NJ: Aronson.

Young-Bruehl, Elisabeth. (1993). Feminism and psychoanalysis: in the case of anorexia nervosa. Psychoanalytical Psychology, 10, 317-330.

Anorexia

An eating disorder where preoccupation with dieting and thinness leads to excessive weight loss while the individual continues to feel fat and fails to acknowledge that the weight loss or thinness is a problem.

Symptoms of anorexia, or anorexia nervosa, include significant weight loss, continuation of weight loss despite thinness, persistent feeling of being fat even after weight loss, exaggerated fear of gaining weight, loss of menstrual periods, preoccupation with food, calories, nutrition and/or cooking, dieting in secret, compulsive exercising, sleep disorders, and a pattern of binging and purging. The condition also has psychosexual effects. The sexual development of anorexic adolescents is arrested, while adults who have the disease generally lose interest in sex. While the term anorexia literally means "loss of appetite," anorexics generally do feel hunger but still refuse to eat.

The great majority of anorexics (about 95 percent) are women. Risk factors for the disorder may include a history of alcoholism and/or depression , early onset of puberty , tallness, perfectionism , low self-esteem , and certain illnesses such as juvenile diabetes. Psychosocial factors associated with the disease are over-controlling parents, an upwardly mobile family , and a culture that places excessive value on female thinness. Emotionally, anorexia often involves issues of control; the typical anorexic is often a strong-willed adolescent whose aversion to food is a misdirected way of exercising autonomy to compensate for a lack of control in other areas of his or her life.

Medical consequences of anorexia may include infertility, osteoporosis, lower body temperatures, lower blood pressure, slower pulse, a weakened heart, lanugo (growth of fine body hair), bluish hands and feet, constipation, slowed metabolism and reflexes , loss of muscle mass, and kidney and heart failure. Anorexics also have been found to have abnormal levels of several neurotransmitters, which can, in turn, contribute further to depression. People suffering from anorexia often must be hospitalized for secondary medical effects of the condition. Sometimes the victim must be force-fed in order to be kept alive. Due to medical complications as well as emotional distress caused by the disorder, anorexia nervosa is one of the few mental disorders that can be fatal. The

American Psychiatric Association estimates that mortality rates for anorexia may be as high as 5 to 18 percent.

According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), anorexia nervosa and its related disorders, bulimia and binge eating disorder, afflict an estimated seven million women and one million men in the United States. The peak times of onset are ages 12 to 13 and age 17. The American Anorexia and Bulimia Association (AABA) calculates that as many as 1 percent of teenage girls become anorexic and 10 percent of those may die as a result.

In order to reduce the risks of eating disorders , cultural ideals connecting thinness and beauty to self-worth and happiness must change so that children establish healthier attitudes and eating behaviors, and learn to value themselves and others for intrinsic qualities, rather than extrinsic ones focusing on appearance. Treatment and cure for anorexia are possible through skilled psychiatric intervention that includes medical evaluation, psychotherapy for the individual and family group, nutritional counseling, and possibly medication and/or hospitalization. With treatment and the passage of time, about 70 percent of anorexics eventually recover and are able to maintain a normal body weight.

The American Anorexia and Bulimia Association is the principal and oldest national non-profit organization working for the prevention, treatment, and cure of eating disorders. Its mission is inclusive of sufferers, their families, and friends. The AABA publishes a quarterly newsletter reviewing developments in research and programming. It also organizes a referral network which includes educational programs and public information materials, professional services and outpatient programs, patient and parent support groups, and training of recovered patients as support group facilitators.

See also Body image; Bulimia

Further Reading

Epling, W. Rank. Solving the Anorexia Puzzle. Toronto: Hogrefe and Hubers, 1991.

Maloney, Michael. Straight Talk About Eating Disorders. New York : Facts on File, 1991.

Further Information

American Anorexia and Bulimia Association (AABA). 418 E. 78th Street, New York, New York 10021, (212) 734–1114.

American Dietetic Association (ADA) NCDC-Eating Disorders. 216 W. Jackson Blvd., Chicago, Illinois 60606,(800) 366–1655.

National Anoretic Aid Society. 445 E. Dublin-Granville Road, Worthington, Ohio 43229, (614) 436–1112.

National Association of Anorexia Nervosa and Associated Disorders (ANAD). Box 7, Highland Park, Illinois 60035,(708) 831–3438.

Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by an extreme reduction in food intake leading to potentially life-threatening weight loss. This syndrome is marked by an intense, irrational fear of weight gain or excess body fat, accompanied by a distorted perception of body weight and shape. The onset is usually in the middle to late teens and is rarely seen in females over age forty. Among women of menstruating age with this disorder, amenorrhea is common.

A clinical diagnosis of anorexia nervosa necessitates body weight less than 85 percent of average for weight and height. Subtypes of this disorder include the binge eating/purging type (bingeing and purging are present) or the restricting type (bingeing and purging are absent).

see also Addiction, Food; Body Image; Bulimia Nervosa; Eating Disorders; Eating Disturbances.

Karen Ansel

Bibliography

American Dietetic Association (1998). Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorder Not Otherwise Specified (EDNOS). Chicago: Author.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: Author.

Escott-Stump, Sylvia, and Mahan, L. Kathleen (1996). Krause's Food, Nutrition, and Diet Therapy, 9th edition. Philadelphia: W. B. Saunders.

Olson, James A.; Shike, Moshe; Shils, Maurice E. (1994). Modern Nutrition in Health and Disease. Media, PA: Williams & Wilkins.

ANOREXIA

The eating disorder known as anorexia nervosa is commonly described as "self-starvation." Characteristics of the disorder include a refusal to maintain a minimally normal weight, an intense fear of gaining weight, a disturbed and unrealistic body image, and (in women) the absence of menstrual periods. (Low body weight and/or the cessation of menses distinguishes anorexia from the related disorder, bulimia.) Sufferers may starve themselves simply by restricting the amount of calories or types of food they consume; or there can be a pattern of excessive binge eating followed by purging through self-induced vomiting, inappropriate use of laxatives or enemas, or excessive exercise.

Female gender, low self-esteem, genetics, and social emphasis on thinness all increase the risk for this condition. The consequences of untreated anorexia can be severe, including electrolyte disturbances, heart rhythm abnormalities, and death. Treatment usually involves psychotherapy, medication, nutrition education, and family therapy.

Leonard J. Haas

Trish Palmer

(see also: Eating Disorders; Menstrual Cycle; Mental Health; Nutrition; Social Determinants )

ANOREXIA NERVOSA

DEFINITION

Anorexia nervosa is an eating disorder that occurs primarily among girls and women. It is characterized by a fear of gaining weight, self-starvation, and a distorted view of body image. The condition is usually brought on by emotional disorders that lead a person to worry excessively about the appearance of his or her body. There are generally two types of anorexia: one is characterized by strict dieting and exercising; the other type includes binging and purging. Binging is the act of eating abnormally large amounts of food in a short period of time. Purging is the use of vomiting or other methods, such as laxatives, to empty the stomach. An individual who suffers from anorexia is called anorexic.

Anorexia Nervosa: Words to Know

Amenorrhea:

Absence of menstrual periods.

Binge eating:

A pattern of eating large quantities of food in a short period of time.

Purging:

The use of vomiting or other techniques to empty the stomach of food.

DESCRIPTION

Anorexia nervosa was first classified as a psychiatric (mental) disorder in 1980 and has since become a growing problem in the United States. The number of cases has doubled since 1970, and experts now estimate that 0.5 to 1 percent of all white females may be anorexic. About 90 percent of all anorexics are female, although the number of males with the disorder is growing. The most common age at which the disorder first appears is fourteen to eighteen years. However, anorexia nervosa may begin later in life; some cases of the disorder have been documented in infants. Studies indicate that the disorder is increasing among women of all races and social classes in the United States.

Anorexia nervosa is a very dangerous disorder. It has a very high rate of mortality (death). In addition, it can cause some serious long-term health effects. These effects include a reduced rate of growth, dental problems, constipation, stomach rupture, anemia (see anemia entry), loss of kidney function, heart problems, and osteoporosis (weakening of the bones; see osteoporosis entry).

CAUSES

The exact cause of anorexia nervosa is not known. However, a combination of factors are believed to contribute to the disorder.

Social Influences

American society places high value on thinness among women. Many consider being thin an essential part of beauty and young girls often think that they must be slender to be attractive. Being thin is also equated with social success. Images of girls and women in mass media (magazines, television, and movies) have been blamed, in part, for reinforcing such stereotypes. Some girls become anorexic as a form of copy-cat behavior. They imitate the actions of other women whom they admire. Extreme dieting may be one of these behaviors.

Occupational Goals

Some occupations traditionally expect women be slender. Dancers, fashion models, gymnasts, and actresses are often expected to be very thin. A young girl who aims for these careers may decide to pursue an extreme weight-loss program.

Genetic and Biological Factors

Anorexia nervosa seems to run in some families. Women whose mothers or sisters have the disorder are more likely to develop the condition than those who do not have relatives with anorexia nervosa.

Psychological Factors

One factor possibly leading to anorexia nervosa is the way a person looks at the world. Many theories have been developed to explain how an individual's view of the world may lead to the disorder. Anorexia nervosa has been interpreted as:

• A fear of growing up. By becoming anorexic, a young girl may be able to remain a child.

• Reaction to sexual assault or abuse.
• A desire to remain weak and passive in the belief that men will find this attractive.
• A drive to be perfect in every part of life, whether it be school work or weight control.
• Response to family problems.
• Biological or psychological problems caused by incorrect feeding experiences at an early age.

SYMPTOMS

The symptoms of anorexia nervosa vary widely. In some people, they are very severe. In others, they are quite mild. In most cases, anorexics tend to have very thin bodies, dry or yellowish skin, and very low blood pressure. Young girls often have amenorrhea (pronounced a-men-uh-REE-uh), the failure to menstruate. They may also experience abdominal pain, constipation, and lack of energy. Chills, the growth of downy body hair, and damaged tooth enamel (from vomiting) are other symptoms of the condition.

DIAGNOSIS

Anorexia nervosa is often difficult to diagnose for a number of reasons. Most people with the disorder deny that they have a problem. They may not get professional help until a family member intervenes and takes them to a doctor.

A physical examination and medical history will be conducted by the physician. Other possible causes for symptoms must first be ruled out. Brain tumors, diseases of the digestive tract, and other conditions can produce symptoms similar to those of anorexia nervosa. Blood tests, urinalysis, and other tests can be used to eliminate other possibilities.

Some psychiatric conditions also produce symptoms like those of anorexia nervosa. Doctors may use certain written tests to distinguish between these disorders and anorexia nervosa. The Eating Attitudes Test and the Eating Disorder Inventory are two such tests.

TREATMENT

Treatment of anorexia nervosa is often quite complicated. The patient may have to deal with immediate problems as well as long-range ones. A variety of professional helpers may be needed. They may include psychiatrists or psychologists, dietitians, and medical specialists in other areas. Treatment is often difficult because of a patient's attitude. He or she may refuse to take the steps necessary to be cured of the disorder.

Hospital Treatment

Serious cases of anorexia nervosa may require hospital treatment. Some symptoms that may lead to hospitalization include:

• A weight of 40 percent or more below normal, or weight loss of 30 pounds or more over a three-month period
• Severely disturbed metabolism (body reactions by which energy is produced)
• Severe binging and purging
• Signs of mental disorders
• Severe depression or risk of suicide
• Family crisis

Hospital treatment has two objectives. First, the patient is given the opportunity to eat on a more normal schedule. In extreme cases, it may be necessary to force-feed the patient. Second, he or she is provided with group or individual counseling. The purpose of counseling is to help the patient understand the reasons for his or her disorder.

Outpatient Treatment

Patients whose health is not seriously at risk can be treated on an out-patient basis. Outpatient services are provided in a hospital or doctor's office. The patient comes in for help but then goes home after the session is over. Most outpatient services for anorexics involve counseling. The counseling can be done on an individual basis or in groups. In some cases family therapy can be helpful. Family therapy helps relatives of the anorexic to understand their role in the patient's problems.

Medications

Drugs can sometimes by used to treat the psychological aspect of anorexia nervosa. They may help patients become less depressed, less anxious, and better able to think clearly about his or her problems.

PROGNOSIS

According to the best estimates available, about half of all anorexics make a good physical and social recovery. About three-quarters gain weight. On a long-term basis, about 10 percent of all anorexics eventually die from the disorder. The most frequent causes of death are starvation, imbalances of chemicals in the body, heart failure, and suicide.

PREVENTION

Anorexia nervosa is likely to remain a problem until overall changes in society occur. As long as thinness is an ideal, anorexics will exist. Educational programs in the schools and discussions at home can help young people to think about and develop positive attitudes toward food, weight control, and body image.

FOR MORE INFORMATION

Books

Hall, Lindsey, and Monika Ostroff. Anorexia Nervosa: A Guide to Recovery. Carlsbad, CA: Gurze Design & Books, 1998.

Hornbacher, Marya. Wasted: A Memoir of Anorexia and Bulimia. New York: Harpercollins, 1999.

Robbins, Paul R. Anorexia and Bulimia. Hillside, NJ: Enslow Publishers, 1998.

Organizations

American Anorexia/Bulimia Association. 165 West 46th Street, Suite 1108, New York, NY 10036. (212) 575–6200.

Anorexia Nervosa and Related Eating Disorders. PO Box 5102, Eugene, OR 97405. (541) 344–1144.

Center for the Study of Anorexia and Bulimia. 1 W. 91st Street, New York, NY 10024. (212) 595–3449.

Eating Disorder Awareness & Prevention. 603 Steward St., Suite 803, Seattle, WA 98101. (206) 382–3587.

National Association of Anorexia Nervosa and Associated Disorders. Box 7, Highland Park, IL 60035. (708) 831–3438.

National Eating Disorders Organization. 6655 South Yale Avenue, Tulsa, OK 74136. (918) 481–4044.

National Institute of Mental Health Eating Disorders Program. Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496–1891.

Web sites

"Anorexia." Healthtouch.com [Online] http://www.healthtouch.com/level1/leaflets/115207/115207.htm (accessed on June 15, 1999).

Anorexia Nervosa and Related Eating Disorders, Inc. [Online] http://www.anred.com (accessed on June 15, 1999).

"A Teen Guide to Eating Disorders." [Online] http://kidshealth.org (accessed on October 5, 1999).

"Understanding Eating Disorders." [Online] http://www.ndmda.org (accessed on June 15, 1999).

anorexia (an-er-eks-iă) n. loss of appetite combined with weight loss. a. nervosa a psychological illness, most common in female adolescents, in which the patients starve themselves or use other techniques, such as vomiting or taking laxatives, to induce weight loss. The result is severe loss of weight, often with amenorrhoea, and sometimes even death from starvation. The problem often starts with an obsessive desire to lose weight but the underlying cause of the illness is more complicated. Patients must be persuaded to eat enough to maintain a normal body weight and their emotional disturbance is usually treated with psychotherapy. See also bulimia.

Anorexia

Fear of Fat

What Causes Anorexia?

What Can Happen When Someone Has Anorexia?

What Can Be Done About Anorexia?

Resources

Anorexia (an-o-REK-see-a) is an eating disorder* involving excessive dieting, preoccupation with food, distorted body image, fear of getting fat, and rapid, significant weight loss. The disorder primarily affects young women.

* eating disorder

is a condition in which a person’s eating behaviors and food habits are so unbalanced that they cause physical and emotional problems.

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Eating disorders

Food and nutrition

Weight loss

Wendy has been taking ballet since she was 5. For as long as she can remember, her dream has been to dance professionally after she graduates from high school. This spring, the young dancer’s company will perform the ballet Swan Lake, and Wendy hopes to be chosen for the lead part.

But since she turned 13 last summer, Wendy has noticed that her figure has started to round out. Constantly in front of the mirror in the dance studio, Wendy cannot help seeing every new curve of her body, and she feels self-conscious about how her growing breasts look in her skintight dancewear. She is worried about gaining weight. What if she becomes too heavy for her dance partner to lift? With try-outs for the spring ballet coming up soon, Wendy fears a tinier dancer will be chosen for the lead instead of her. Lately, she has been wishing for the body she had at 11: tiny and light, like the “perfect” ballerina she dreams of being.

For the past month, Wendy has been on a crash diet, keeping a strict record of everything she eats. She weighs herself morning and night. When there is time, she jogs after dance class. She is relieved to have lost some weight and wants to keep going. She has been allowing herself only the tiniest portions of food and has started to skip lunch altogether. Pleased with her weight loss so far, she decides to cut back to just a small salad for dinner and maybe just a yogurt for breakfast.

Fear of Fat

No one sets out to have anorexia. It takes hold slowly and might start with a simple desire to lose a few pounds. However, in fully developed cases, people with anorexia are malnourished, often depressed, obsessed with food or exercise, and still are convinced that they are fat.

An anorexic person has a distorted perception of what her body actually looks like. She may lose a little weight from a normal diet, gain positive attention from people around her, and then become obsessed with losing more and more weight. But no matter how thin she gets, she still sees her body as unacceptable and unattractive. Photo Researchers, Inc.

People with anorexia refuse to eat enough food to maintain normal healthy body weight. Because they fear getting fat, people with anorexia use extreme dieting to lose a lot of weight rapidly. They also may exercise excessively to burn off calories. People with anorexia lose at least 15 to 20 percent of their normal body weight. For example, a girl who starts out at 130 pounds might drop to 100 pounds. Anorexia involves a distorted awareness of the body. People with this condition become preoccupied with thinness and may continue to believe that they are fat even though others around them may see them as unnaturally thin. Over time, the weight that people with anorexia want so desperately to control can become frighteningly out of control for them.

Anorexia is much more common among girls (90 to 95 percent of cases), but boys can have it too. At least 1 in 100 young women in the United States have anorexia, and the disorder usually begins during adolescence. Girls who participate in activities that value thinness, such as dancing, gymnastics, or figure skating, are at higher risk than others for developing anorexia.

What Causes Anorexia?

No single factor causes anorexia. Emotional problems, family difficulties, social pressure, and biological variability all play a role. Contemporary society’s glamorization of thinness influences many girls to diet excessively. Once started, some extreme dieting practices can be hard to stop. Girls who have a high need for perfection and control may see dieting as a way to be the prettiest, thinnest, and most perfect of their peers, or to live up their parents’ expectations for perfection, or to look as perfect as models or stars they admire. Girls with anorexia tend to come from loving, highly controlled families. A girl who feels that she does not have enough independence may use control of eating as a way to assert herself. In other cases, anorexia may develop because of pressure to be extra-thin when certain sports or activities demand it.

What Can Happen When Someone Has Anorexia?

Anorexia can cause a number of serious medical problems, such as disturbed heart rhythms and vitamin and mineral deficiencies that can harm vital organs. With anorexia, the body is literally starving. Bone and muscle begin to waste away. Blood pressure and body temperature drop because the body cannot maintain them properly. Hair, nails, and skin become dry and brittle. Girls with anorexia often stop getting their periods*,

* period , or menstruation

(menstroo-AY-shun), refers to the monthly flow, or discharge, of the blood-enriched lining of the uterus that normally occurs in women who are physically mature enough to bear children. Most girls have their first period between the ages of 9 and 16. Because it usually occurs at four-week intervals, it is often called the “monthly period.”

Athletes And Anorexia

Girls and young women involved in sports that place a high value on thinness are three times more likely than others to develop anorexia or bulimia (bu-LEE-me-a; binge eating followed by vomiting or other methods of emptying the stomach). A 1992 study conducted by the American College of Sports Medicine estimated that as many as 62 percent of females involved in sports like gymnastics and figure skating struggled with eating disorders. Many well-known athletes have spoken out about their battles with eating disorders, including gymnasts and Olympic gold medal winners Nadia Comaneci and Kathy Rigby. Christy Henrich, who in 1989 was ranked the #2 gymnast in the United States, died from complications of anorexia in 1994 at the age of 22. The pressure to be thin does not appear to be easing up. The average gymnast in 1976 was 5’3” tall and weighed 105 pounds; the average gymnast in 1992 was 4’9” tall and weighed 88 pounds.

and overall body growth and development can begin to slow down. Without treatment, anorexia can cause irreversible damage to the body. It can lead to heart failure* and sometimes death. In the United States, about 1,000 young women die each year from complications of anorexia.

* heart failure

is a medical term used to describe a condition in which a damaged heart cannot pump enough blood to meet the oxygen and nutrient demands of the body. People with heart failure may find it hard to exercise due to the in-sufficient blood flow, but many people live a long time with heart failure.

What Can Be Done About Anorexia?

There is help for people with anorexia, but it sometimes takes others to convince people with this problem that they need help. Family members or friends may ask about the weight loss. A girl with anorexia may be ashamed or self-conscious and may say she does not have a problem. Many girls with anorexia resist getting help because they do not want to gain weight. Seeking help sooner, rather than later, can be life-saving, but the distorted body image that is part of anorexia can make it hard for people with the condition to realize how dangerously thin they are.

Treatment for anorexia typically includes several parts and a few different health professionals. Treatment may begin with a medical visit to evaluate nutritional status and overall health. The doctor may ask about weight loss, order blood tests, and ask about the patient’s eating habits and feelings about her body. Nutritional counseling helps with planning and following a healthy diet. Individual psychotherapy allows the person to talk about feelings and problems that led up to the anorexia, come up with new solutions, and work on body image. Group therapy brings together people with similar concerns to share their experiences and receive support. Medications are sometimes used to reduce anxiety* and depression*. If a person with anorexia is in a severe health crisis, she may have to be hospitalized to stabilize her medical condition and become better nourished before other aspects of treatment can begin.

* anxiety

can be experienced as a troubled feeling, a sense of dread, fear of the future, or distress over a possible threat to a person’s physical or mental well-being.

* depression

(de-PRESH-un) is a mental state characterized by feelings of sadness, despair, and discouragement.

See also

Binge Eating Disorder

Body Dysmorphic Disorder

Body Image

Bulimia

Eating Disorders

Peer Pressure

Resources

Books

Berg, Frances M. Afraid to Eat: Children and Teens in Weight Crisis. Hettinger, ND: Healthy Weight Journal, 1997.

Brumberg, Joan Jacobs. Fasting Girls: The History of Anorexia Nervosa. New York: Vintage Books, 2000.

Levenkron, Steven. Anatomy of Anorexia. New York: W. W. Norton and Company, 2001.

Organizations

American Anorexia Bulimia Association, Inc., 165 West 46th Street,
Suite 1108, New York, NY 10036. Telephone 212-575-6200 http://aabainc.org

Eating Disorders Awareness and Prevention, Inc. (EDAP), 603 Stewart Street, Suite 803, Seattle, WA 98101. Telephone: (800) 931-2237 for toll-free information and referral hotline http://www.edap.org

National Association of Anorexia Nervosa and Associated Disorders (ANAD), P.O. Box 7, Highland Park, IL 60035. Telephone 807-831-3438 http://anad.org

TeensHealth.org, a website sponsored by the Nemours Foundation and the Alfred I. duPont Hospital for Children, Wilmington, DE, contains information about anorexia and other eating disorders. http://www.teenshealth.org

anorexia nervosa A psychological disturbance resulting in a refusal to eat, possibly with restriction to a very limited range of foods, and often accompanied by a rigid programme of vigorous physical exercise, to the point of exhaustion. Anorectic subjects generally do not feel sensations of hunger. The result is a very considerable loss of weight, with tissue atrophy and a fall in basal metabolic rate. It is especially prevalent among adolescent girls; when body weight falls below about 45 kg there is a cessation of menstruation. See also bulimia nervosa.

ANOREXIA

This term means a "loss of appetite," especially when prolonged, and came into English in the 1620s from Latin usage, based on Greek stems (a [no] + orexis [appetite]). Anorexia generally leads to loss of weight due to a of loss of appetite; anorexia nervosa is an appetite disorder associated with severe weight loss. Eating disorders of this type and those associated with compulsive eating are, in some ways, behavioral equivalents of drug abuse.

(See also: Overeating and Other Excessive Behaviors )

Timothy H. Moran

an·o·rex·i·a / ˌanəˈreksēə/ • n. a lack or loss of appetite for food (as a medical condition). ∎  (also an·o·rex·i·a ner·vo·sa / nərˈvōsə/ ) an emotional disorder characterized by an obsessive desire to lose weight by refusing to eat; compare with bulimia.

an·o·rex·ic / ˌanəˈreksik/ (also an·o·rec·tic / ˌanəˈrektik/ ) • adj. relating to, characterized by, or suffering from anorexia. ∎ inf. extremely thin. • n. 1. a person suffering from anorexia. 2. (anorectic) a medicine that produces a loss of appetite.

anorexia nervosa Abnormal loss of the desire to eat. A pathological condition, it is seen mainly in young women anxious to lose weight. It can result in severe emaciation and in rare cases may be life-threatening. See also bulimia nervosa

anorexia nervosa see eating disorders .

Anorexia Nervosa

SeeEating Disorders

anorexia Lack of appetite.

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