Anorexia nervosa

Overview
Anorexia nervosa is a type of eating disorder in which a person refuses to maintain a minimal normal body weight, has a distorted body image of delusional proportion, and is intensely afraid of gaining weight. The primary characteristic of anorexia is not maintaining a body weight of at least 85 percent of what is considered healthy for the person's height and age.
There are two types of anorexia -- restricting and binge eating/purging. With the restricting type, the person accomplishes weight loss from fasting, dieting or excessive exercise and doesn't engage in binge eating or purging behavior. With the binge eating/purging type, the person regularly engages in binge eating or purging behavior. The occurrence of each type of anorexia is fairly even.

Anorexia is far more common in industrialized countries in which food is abundant and attractiveness is linked to thinness, including the United States, Canada, Australia, Japan, New Zealand, South Africa and European countries. Like other types of eating disorders, anorexia occurs in all social classes and ethnic groups. Because eating disorders are more commonly associated with Caucasian females, they may be underdiagnosed in other ethnic groups.

Although anorexia is diagnosed in males, the female to male ratio is at least 10 to 1. It typically begins in mid to late adolescence (between ages 14 and 18). Anorexia rarely develops before puberty or after age 40.

Certain characteristics of anorexia may overlap with those of bulimia (an eating disorder in which binge eating and inappropriate methods are used to prevent weight gain), but one main difference is that people who have anorexia are not able to maintain body weight at or above a minimally normal level.


Causes/associated factors
The causes of anorexia are complex, but the following factors may play a role.
Researchers have found that people who develop anorexia often have coexisting conditions such as depression, personality disorders, obsessive compulsive disorder (OCD) or substance use disorders.

People who have anorexia normally have compliant personalities. Low self-esteem and feelings of helplessness are also characteristic traits. They are typically perfectionists and good students. The desire to control their own lives may be manifested through eating because eating may be the only activity they feel able to control or direct.

Genetic or familial factors
People who have anorexia typically come from Caucasian, middle- to upper-class families who emphasize high achievement, perfection and physical appearance. It tends to run in families, and there is an increased risk for first-degree biological relatives of people who have anorexia. Some experts link anorexia to family dynamics. Families of people who have anorexia are often described as being overly rigid with rules, which prevents individuality. Parents may give conflicting messages about independence and autonomy. Emotional expression may be avoided, and open communication is inhibited. In some cases, anorexia may be the child's attempt to hold the family together by becoming the object of common concern.

Biochemistry
Anorexia may be related to decreased levels of serotonin (a natural chemical that constricts blood vessels and is thought to be important for sleep and sensory perception levels, as well as appetite control). The body produces serotonin with the help of tryptophan, which can only be produced through the digestion of food. When you starve yourself, your body won't produce enough tryptophan to produce serotonin. In turn, lack of serotonin may perpetuate anorexic eating patterns, such as self-starvation or impulsive eating.

The athletic connection
Participation in occupations or activities that emphasize weight -- such as gymnastics, figure skating, ballet and wrestling, or endurance sports such as track and cross country -- leads to greater risk for anorexia.


Characteristics
Physical characteristics
Again, anorexia is characterized by a body weight less than 85 percent of what is considered healthy for the person's height and age. Anorexia can cause the person's skin to become dry and scaly, often with a yellow or gray cast. The person may also develop brittle nails and hair, hair loss and dental problems, such as eroded tooth enamel, cavities, tooth discoloration, lip sores and loss of taste. Generally, people who have anorexia are more susceptible to infections. Some develop a growth of fine body hair. Dehydration, lethargy, low blood sugar and circulation problems, such as cold extremities or a general intolerance to cold, are also common. Anemia (a condition marked by a decreased number of red blood cells or hemoglobin, a protein in red blood cells that contains iron) may also develop.

Psychological characteristics
People who have anorexia are often perfectionists who tie their sense of self-worth to weight, body shape or thinness. They often feel the need to please others. Body image is distorted, and there is an intense fear of gaining weight or getting fat. Some people who have anorexia may consider the gastrointestinal tract dirty and restrict eating, abuse laxatives, or take frequent enemas (solutions used to stimulate bowel movements) to keep it clean. People who have anorexia typically deny being hungry or underweight. Fears of adult sexuality, expressing feelings and losing control are also common.

Behavioral characteristics
The person may exercise excessively and obsessively check his or her weight or judge size with a tape measurer, mirrors or photos. The person may lose a large amount of weight rapidly, and then hide it through baggy or layered clothing. Dieting may continue even after meeting a weight loss goal. Daily food intake may significantly decrease, and the person may secretly eat. Sometimes, frantic activity alternates with lethargy and depression.

A person who has anorexia may have an unusual interest in food preparation and/or calorie counting. He or she may encourage others to eat while personally avoiding eating or being extremely selective (choosing only low-calorie foods, for example). At meal time, the person may follow strict eating rituals, push food around the plate, make chewing mouth movements, or refuse to eat in front of others.


Diagnosis
If you suspect you or someone you care about has an eating disorder, first consult a medical doctor to evaluate any possible physical or organic causes for the symptoms. Diagnosis is based on a history of the symptoms listed above. Diagnostic studies, including blood tests, liver function tests, urinalysis and an electrocardiogram (a recording of the electrical activity of the heart), are typically done. Depending on the circumstances, other tests may be needed as well.

Treatment
Because eating disorders are so complex, they're best treated through a team approach with multiple health care providers. Many clinics have eating disorders programs. Keep in mind that people who have anorexia rarely seek professional help on their own. They're often referred by parents, school officials or employers. Even then, treatment often comes only after giving false assurances and reaching dangerous levels of weight or electrolyte imbalance. Often, people who have anorexia must be forced into treatment. The earlier the treatment begins, however, the better the chances for full recovery.
Generally, treatment involves:

medical intervention to resolve the physical complications of starvation
nutritional counseling to help restore normal nutritional status and promote weight gain and maintenance
individual and/or family counseling to learn about the disease and how to adopt or encourage more healthful habits, promote the long-term change of attitudes, perceptions and behaviors, and recognize the internal critical voice in favor of a more nurturing thought pattern
support groups, for both the patient and his or her family members
dental care
medication therapy, such as appetite stimulants or antidepressants
Exploring new ways to meet personal needs and improve coping skills is often beneficial. For example, assertiveness training and learning how to communicate effectively could be helpful. Based on the high mortality rate associated with anorexia, ongoing medical supervision is crucial. If severe or life-threatening physical complications exist, hospitalization for intensive treatment may be necessary.

Self-care strategies
If you're coping with an eating disorder, there are things you can do in your recovery process. Keep all appointments with your doctor or therapist. Set realistic goals for your weight and personal achievements. Build self-esteem, keep stress under control, and avoid self-judgment. Maintain a positive attitude, and learn to accept yourself and your body as you are. Communicate your feelings and work out conflicts. Remember that support from a professional as well as family and friends is essential.

It's also important to eat a healthful diet with regularly scheduled meals, and avoid alcohol and cigarettes. Get plenty of rest, maintain your recommended ideal weight, moderate your exercise habits, and take any medication as prescribed.

Tips for friends and family members
If you have a friend or family member who has anorexia, keep the following considerations in mind.

Do not focus on controlling the person's eating or weight. Remember that the person's behavior is an attempted solution to a problem, and, most often, one of the problems the person is attempting to solve is a perceived lack of control over his or her life. The person may resist your efforts to control what he or she considers the one thing in life that he or she actually has full control over.

Recognize your limitations. Assuming the person is an adult and he or she is not presenting an immediate danger to himself, herself or others, no one can force him or her to get help. However, you can express your concern in a loving way, find community resources and treatment programs, and encourage the person to seek help.

Recognize the normal feelings often experienced by friends or family members of people who have eating disorders. These include fear about the person's well-being or safety and anger that may be directed at the person who has the eating disorder, yourself for not being able to fix the problem, or doctors or other health care providers for not spotting the problem earlier or doing enough to help. Also understand the mistrust that may result from the person's attempts to deceive others and cover up his or her habit out of shame.

Confront the person assertively. Express your concerns about the person's behavior without violating his or her rights or boundaries. Use "I" statements to express your concern. For example, say, "I'm concerned because you seem preoccupied with your weight," instead of, "You're obsessed with your weight." Avoid generalizing the situation too much or placing blame. Be sensitive to the fact that the person may be ashamed or embarrassed about being confronted about his or her "secret." Do not add to the person's potential guilt or remorse with shaming lectures or exhortations.

Be prepared for denial. People who have eating disorders often experience a great deal of shame in connection with their behavior. Denial of the problem is a part of the illness. To prepare for the denial, have in mind specific examples of the behavior you consider problematic.

Offer unconditional support and love. Do not make your love and acceptance conditional on the person's weight, appearance or behavior. Many people who have recovered from eating disorders acknowledge the unconditional love and support of family and friends as a crucial factor in helping them recover.

Learn about eating disorders and seek support from others. You may want to join a support group or look to local organizations or other community resources.

Act immediately if there is a risk for suicide or physical harm or the person's health is compromised.

Relapses
Recovery from an eating disorder is often uneven, and relapses are common. Look for the following warning signs:

weighing 5 pounds or more below the assigned target weight
increase in exercise or food-related behaviors
drug or alcohol use
use of any laxatives, enemas, diuretics or diet pills
change in sleeping habits
If you or a loved one experiences a relapse, contact your health care provider immediately.


Complications
Medical complications of anorexia are primarily due to the effects of malnutrition and purging. If left untreated, anorexia can take a severe toll on the heart. Electrolyte imbalances can cause the heart to beat irregularly and may lead to heart failure. Blood pressure may drop if the heart develops an irregular or slow rhythm. As the heart muscle starves, it loses size and cholesterol levels tend to rise. Heart disease that is often irreversible is the most significant cause of death for people who have severe anorexia.
Anorexia decreases the production of reproductive and thyroid hormones while increasing the production of other hormones. For women, it's common for menstrual periods to stop, which may lead to sterility. About 25 percent of women who have severe anorexia never get their periods again, even after treatment. Women who become pregnant before regaining their weight have a higher risk of miscarriage, low birth weight babies or babies born with birth defects.

Anorexia predisposes women to developing osteoporosis (the loss of bone mass that leads to brittle bones) due to mineral loss, low estrogen levels and increased steroid hormones. As the bones become brittle and fracture easily, spontaneous and stress fractures are common.

In severe cases, anorexia may lead to nerve damage, kidney malfunction, seizures, thinking abnormalities, and tingling or numbness of the hands and feet. For children and adolescents, severe anorexia may lead to permanent brain damage. Less than two-thirds of people who develop anorexia as children or adolescents recover. The risk of death increases significantly if body weight reaches 60 percent below normal.


Prevention
Many of the self-care strategies outlined above can also be used to help prevent anorexia. Remember, reasonable eating and exercise habits, a positive outlook and solid self-esteem can create a healthy lifestyle that lasts a lifetime.