Eating Disorder: ANOREXIA NERVOSA
-Namitha Babu, Psychologist
Anorexia nervosa is a serious mental illness characterized by the maintenance of an inappropriately low body weight, a relentless pursuit of thinness related to the intense fears of obesity, and distorted cognitions about body shape and weight. It is associated with an exaggerated dread of weight gain and fat, often in spite of emaciation, and to the detriment of other physical and psychological aspects of the individual’s life. The person with anorexia nervosa begins dieting in an attempt to lose weight. Over time, achievement of ever decreasing weights becomes a sign of mastery, control, and virtue. The terrifying illness-anorexia nervosa develops insidiously in adolescents as well as at other crisis points in life.
Many psychiatrists considered anorexia nervosa to be a variant of some other psychiatric illness, such as schizophrenia, affective disorder, obsessional neurosis, or hysteria. Of these, the most frequent has been that anorexia nervosa is an expression or form of affective illness, since depressive symptoms like dysphoric mood, low self-esteem, hopelessness and suicidal tendencies were frequently reported. (Anorexia nervosa | University of Maryland
Medical Center http://umm.edu/health/medical/altmed/condition/anorexia-nervosa#ixzz3piCErCX4, Garfinkel & Garner 1982)
There are two subtypes to anorexia nervosa
- The restricting type
- The binge-eating/purging type
In the restricting type, the quantity of food intake is very limited as well as the calories consumed is tightly restricted. The binge-eating/purging type differs from the restrictive type as the patients either binge, purge or binge and purge. The binge involves out-of-control intake of excessive amounts of food and will be followed by an action of purging where the person makes attempts of self-induced vomiting or misuse of laxatives, diuretics and enemas.
CRITERIA FOR ANOREXIA NERVOSA (DSM-IV-TR)
- Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
- In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.(A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., oestrogen, administration).
SIGNS AND SYMPTOMS OF ANOREXIA NERVOSA
The primary sign of anorexia nervosa is sever weight loss due to strict control over food. People suffering from anorexia nervosa may engage in binge-eating/purging and later force themselves to do excessive exercise and make attempts of self-induced vomiting or intake of laxatives. Low blood pressure, weakness, dizziness, heart palpitations, constipation, diarrhoea, amenorrhea, brittle nails, dry skin, thinning hair, scanty or absent menstrual cycle in women, bloated or upset stomach, feeling cold, swollen ankles/puffy hands are the most frequent physical symptoms of anorexia nervosa.
An anorexic person has an emaciated appearance with protruding bones, dry hair, baby fine hair covering the face and other parts of the body (lanugo), cracked lips, orange palms/yellow skin as well as a swollen face. The silent symptoms or after effects of anorexia nervosa can be brain shrinkage, osteoporosis (thinning of bones), anaemia, low white blood cells (the cells that fight infection), impaired fertility and impaired kidney functioning.
PSYCHOLOGICAL AND BEHAVIOURAL SYMPTOMS
Psychological repercussions include violent mood swings, feelings of isolation and depression, mostly accompanied by an erosion of self-esteem. Anorexia nervosa is characterized by disturbed thinking and distorted self-perception (insisting they are overweight when they are thin).Being preoccupied or obsessed with food as well as refusal to eat is mainly seen in anorexics. Starvation will make thinking a slower process and will
impair the short-term memory. Most anorexics display obsessive-compulsive behaviours. Their obsession is not only restricted to food or weight loss, but may develop a compulsion towards punctuality, neatness and order. They seem to be depressed and constantly evaluate themselves in terms of weight and appearance. The lack of self-esteem and distorted self-image leads to emotional instability as well as withdrawal from interpersonal relationships in favour of social isolation.
RISKS AND CAUSAL FACTORS OF ANOREXIA NERVOSA
Anorexia nervosa is considerably more prevalent among the adolescents, especially seen in teens and young adult women. Early feeding difficulties, dieting, weight gain, depression, having obsessive compulsive disorder (OCD-compulsive behaviour seen in most of the patients) or other anxiety disorders, puberty, the influence of media or professions that prize a lean body, history of sexual abuse, internalizing the thin ideal, perfectionism, negative body image, negative emotionality are all the major risk factors in the development of anorexia nervosa.
The genetic factors in developing anorexia nervosa have now been keenly studied. This is because, the tendency to develop anorexia nervosa has been shown to cluster in families. Children of parents who have a history of anorexia, is seen to inherit the disorder rather than the children of parents with healthy eating habits. There is also provocative evidence for a gene (or genes) on chromosome 1 that might be linked to susceptibility to the restrictive type of anorexia nervosa (Grice et al., 2002).
Hypothalamus is the part of the brain that is associated with eating. But there is no enough evidence that the hypothalamus plays any role in the development of eating disorders. However, Uher and Treasure (2005), reviewed a series of case studies of patients with tumours in the hypothalamus found that even though there was sometimes an association with increase or loss of appetite, there was no evidence that they resulted in any specific eating disorders. But the interesting fact in the study was that, the temporal cortex, which is known to be associated with body image perception and the frontal cortex (particularly the orbitofrontal cortex), that monitors the pleasantness of stimuli such as smell and taste, when damaged was linked to the development of anorexia nervosa.
Serotonin is a neurotransmitter that modulates appetite and feeding behaviour. It is also implicated in mood disorders, impulsivity and obsessionality. Serotonin is made from an essential amino acid called tryptophan which can only be obtained from food. When tryptophan is consumed, it is converted in to serotonin through a biochemical conversion process. People with anorexia nervosa are seen to have low levels of serotonin. When the levels of serotonin disrupts, levels of anxiety and compulsivity increases which might also lead to binging and purging ( Bailer & Kaye,2011).
The Western culture idealises feminine beauty as a slender once since the 1920s. Since then young women has considered thinness as a sign of mastery. The mania of fashionability in media has bombarded the world with glamorous images that does not tolerate imperfection. The British supermodel Kate Moss has glamourized anorexia by describing herself as “rexy”, a hybrid term that combines “anorexic” and “sexy”.A classic study conducted by Anne Becker and her colleagues in 2002 provides us with some anecdotal information as to the way in which the western ideal of thinness has influenced the foreign cultures. This illustration on how the media creates pressures to be thin was conducted in Fiji in the 1990s.The study shows that a considerable percentage of women in Fiji were overweight. This made sense within the Fijian culture as being fat was associated with strength, ability to work, and being kind and generous. Also, the surprising fact was, being thin was considered negative as it was thought to reflect incompetence and poor health. Dieting was considered offensive in the culture and there was total absence of any
kind of eating disorders. But after television came to Fiji, the cultural climate changed. Many young women started watching programs such as Beverly Hills 90210 and Melrose Place and began raising concerns about their weight. Young women started dieting as they were motivated by the desire of becoming like the actors they had seen on television.
TREATMENT OF ANOREXIA NERVOSA
The treatment of anorexia nervosa can be made easier and simpler if recognized early. If the individual is ready to acknowledge the problem, effective treatment can be given at the onset by focusing on helping the individual to take care of their own eating habits. If a person is forced in to treatment against their will, the treatment is unlikely to be successful especially for patients with the binge-purging subtype. Delay in recognition may increase the severity of the condition and might require hospitalization and intravenous feeding. The immediate concern will be to restore the patients’ weight to a level that is no longer life threatening. However, these are the physical aspects of the treatment which is considered to have a short-term effect. The treatment must focus on the psychological factors that fuel the anorexic behaviour.
Family therapy is given mostly to adolescents with anorexia nervosa. The Maudsley model (le Grange & Lock, 2005) is the widely used approach that neither blames the parents nor the child for anorexia nervosa. This treatment program involves 10-20 sessions in about 6 to 12 months and has three phases. The first is the refeeding phase where the therapist guides the parents to help the child to eat healthy once again. The family meals are monitored by the therapist. Next is the relationship phase where the therapist focuses on sorting out the family issues and conflicts. This phase starts only once the patient starts gaining weight. The last one is the termination phase where the focus is on building strong relationship between the parents and the patient. Family therapy is seen to be more effective as most of the adolescents were able to recover and less drop outs were recorded.
COGNITIVE BEHAVIOURAL THERAPY (CBT)
The Cognitive Behavioural Therapy can be considered as a short-term psychotherapy where the therapist guides the individual to the reality by helping them understand facts rather than their feelings of the situation( Freeman,2009). The length of the therapy can be from 1 to 2 years. The major focus of the therapy is to eradicate the distorted perception of the self and modifying the beliefs on food and weight.CBT is not considered to be a very effective method in the treatment of anorexia nervosa as very less percentage of people who underwent CBT recovered fully. This throws light on the need for developing newer methods for people with more intense, deep-rooted problems.
COGNITIVE ANALYTIC THERAPY (CAT)
This is a treatment method that goes back to the past or the early developmental stages to analyse the unhealthy behaviour patterns that might have led to the development of anorexia nervosa. It consists of three stages.
- Reformulation – where the individual recollects information from the past that triggered the development of the unhealthy behaviour.
- Recognition – helping the individual realize how it led to the development of anorexia nervosa.
- Revision – helps the individual to figure out how these behavioural patterns can be changed.
FOCAL PSYCHODYNAMIC THERAPY (FPT)
This therapeutic method focuses on the early childhood experiences of an individual. It helps in overcoming the unresolved conflicts of an individual from within and finds more successful ways to cope stress. The therapy is carried out in 40 sessions. The treatment method involves two steps:
- Helping the individual understand the meaning of food for them
- Helping to find an alternative way to express their distresses
A study conducted by Bewell and Carter examined the effect of readiness to change on the inpatient treatment outcomes of the anorexics. The study was conducted on 127 patients who were consecutively admitted to an intensive inpatient treatment program. They were asked to complete an eating disorder inventory at admission and a measure of readiness to change after 4 weeks of treatment. The study suggests that the readiness to change in a person predicts the success in a treatment program.
Anorexia nervosa is a psychiatric illness in which people die than in any other disorders.Normally, a person who is under treatment recovers in 4 to 7 years.50-70% of anorexics recover completely. Even after recovery, chances to relapse is high in people with thedisorder. A person’s readiness to change is the most important factor in the treatment of anorexia nervosa. The cognitive restructuring in people with anorexia were seen to be more successful in people who had an understanding about the disorder.
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