Anorexia Nervosa

It is estimated that between 0.5% and 3.7% of women will suffer from anorexia nervosa (henceforth called anorexia) at some point in their lives, although it is becoming increasingly common amongst males too. The ratio of male to female sufferers is about 1:10. Anorexia is most likely to develop during adolescence, and it is a disorder characterised by a refusal to maintain a healthy body weight, and an obsessive fear of gaining weight often caused by a distorted body image where the person sees themselves as fat, even though they are often severely underweight. It is a severe mental illness, frequently accompanied by physical problems, and the mortality rate - if left untreated - is fairly high compared with other psychiatric disorders. Anorexia can be hard to diagnose, as sufferers typically attempt to hide their disorder from those around them. And because they tend to deny they have a problem, they often fail to seek help. A diagnosis may not be reached until medical complications have developed, and the condition can no longer be hidden from relatives or from professionals. There is considerable overlap between anorexia and bulimia, although people with bulimia are less likely to be underweight, and tend to have fewer physical complications; typically they binge eat, and then purge themselves, rather than restricting their food intake in the first place.

There is probably no single definite cause of anorexia, and it is likely that a variety of factors - biological, social and emotional - are involved, depending on the individual sufferer. In terms of personality characteristics, a need for control, negative feelings and perfectionism are common features, and sufferers often become obsessive with regard to food and body weight, developing compulsive eating rituals such as cutting up their food into tiny pieces, or preparing elaborate meals for others, whilst denying themselves. Some studies suggest that initial weight loss through normal dieting - and the feelings of mastery and control this gives - may subsequently trigger anorexia in the vulnerable individual, starting a destructive cycle with an exaggerated need to be thin and attractive. Social pressures (for example, peers; the media) are likely to be influential, and some people may be particularly at risk because of their chosen professions, such as dancers, models and athletes. Life stresses such as bereavement or parental divorce are also believed to be potential triggers. Genetic factors probably also come into play, as studies of identical twins have shown that if one twin develops the condition, then the other has a 1 in 2 chance of getting it. Finally, biological factors may be important, and some anorexics have been shown to have a chemical imbalance involving oestrogen (which can lead to feeding suppression), helping to explain why women tend to suffer more than men, and particularly at puberty when hormonal changes are taking place.

Other behaviours common amongst anorexics in addition to severe calorie restriction, are excessive exercise, and misuse of laxatives, diuretics and appetite suppressants. For those with a perfectionist personality, this can help give a feeling of achievement and control even though the reality is that, in time, it is the condition (i.e. anorexia) that is in control, much as in other addictive behaviours. Self-induced vomiting is common amongst bulimics, who may also resort to food during binges to block out disturbing feelings. Sufferers will be preoccupied with the shape and size of their bodies, and take extreme measures to control what they eat. Their lives will tend to revolve around food. As well as causing physical harm to their bodies (for example chemical imbalances, and thinning of the bones), it is also common for the sufferer to become anxious and depressed, to have low self-esteem, and to withdraw from their families and the other people around them.

With early diagnosis and treatment, people can and do overcome anorexia, although it may take months or even years to fully overcome the condition. According to one source, around half of sufferers will make a full recovery, others may fluctuate between being well and suffering occasional relapses, while a small proportion remain chronically ill. Treatment will aim to reinstate healthy eating habits and encourage weight gain, help sufferers to become physically and mentally stronger, and reduce the symptoms and problems that have come to be associated with the condition. Eventually, many people can learn to lead happier and more fulfilled lives, in which they are truly in control.

Behavioural Symptoms

  • obvious, rapid weight loss, often to the point of becoming dangerously underweight
  • an obsession with calorie counting and food restriction
  • rituals around food, such as cutting it into tiny pieces, and hiding or discarding food in a secretive manner
  • an extreme fear of gaining weight, despite being thin
  • misuse of laxatives, diuretics and appetite suppressants
  • excessive engagement in exercise
  • may wear loose-fitting clothing to disguise weight loss, or to cover what they see as an overweight, unattractive body
  • distorted perception of self as being overweight, even when thin
  • self-induced vomiting (particularly in bulimia)
  • obsessively weighing, measuring, and examining the body

Psychological Symptoms

  • lethargy, depression, and withdrawal from those around them
  • may become irritable and easily upset, with mood swings
  • decreased attention and concentration
  • decreased interest in previously enjoyed activities

Physical Symptoms

  • cessation of periods, or delayed puberty
  • stomach pains and constipation
  • disrupted sleep patterns
  • chemical imbalances in the body, e.g. low potassium and calcium levels, causing problems such as tiredness and weakness
  • osteoporosis (in severe cases)
  • organ damage (in severe cases)

Diagnosis & Assessment

Admitting you have a problem can be very hard, but seeking help, and getting an early diagnosis, are very important. If you believe you may suffer from anorexia, a good start is to visit your G.P. who will probably refer you on to a specialist mental health team, including professionals such as psychiatrists, psychologists, dieticians and counsellors. For a diagnosis of anorexia to be reached, the sufferer will have been identified as having problems in four main areas: A refusal to maintain a body weight above 85% of the expected weight for age and height; an extreme fear of gaining weight despite being thin; a distorted perception of one's shape or weight together with a refusal to accept that one is underweight, and finally - in women - missing at least three consecutive periods if the menstrual cycle has begun. Delayed puberty, and behaviours such as self-induced vomiting, excessive exercise, and misuse of laxatives, diuretics and appetite suppressants, are also indicative. Two main subtypes of anorexia have been identified: the binge-eating/purging type, and the restricting type, where food intake is severely limited in the first place.

Treatment

As noted above, treatment may be carried out by a variety of professionals, and medical, nutritional and psychological interventions used in combination have been shown to be most effective. In severe cases the sufferer may be referred to a specialist eating disorder unit. Whether as an in-patient or an out-patient, the main aims of treatment will be to help the person regain a healthy weight; look at the psychological issues related to the condition, and change the thoughts and behaviours that led to the eating disorder in the first place so that the sufferer develops a more healthy attitude towards food and their body image. Self-acceptance is one of the ultimate goals.

A dietician is likely to be involved who will give nutritional advice and counselling, including how to eat healthily to achieve a more normal weight, and to correct any nutritional deficiencies that have occurred. It will be important to re-instate a consistent pattern of eating, including having regular meals. Whilst most psychiatric medications are ineffective in treating the symptoms specific to anorexia, secondary symptoms such as depression may be treated with anti-depressants. Additionally, Olanzapine (an anti-psychotic) can be helpful with obsessional thoughts around food.

Some form of psychological counselling is likely to be offered to get to the problems lying at the heart of the eating disorder, and cognitive behavioural therapy is the most commonly used approach. This can teach the sufferer how certain thinking patterns have contributed to the development of anorexic behaviours, and these can vary from one sufferer to the next. However, it is common to find underlying issues around control, perfectionism and self perception. Generally people diagnosed with anorexia and bulimia have similar distorted thought processes and similar behaviours, even though the initial triggers may be highly specific to the individual. (As noted in the introduction, these causes may be cultural, biological, genetic or psychological, or some combination of these). It will be key to identify the thoughts and assumptions of the individual, and to challenge any false beliefs the person has about their weight and body. At the same time, emotional issues will need to be addressed, such as identifying the feelings and fears that caused the person to stop eating in the first place. It can be helpful to involve the family in therapy, so that they can learn to understand the disorder, and become actively involved in supporting their loved one in their goals towards healthier eating and better emotional adjustment.

Early diagnosis and treatment can improve outcomes for the anorexia sufferer. However, much as in other addictions, effort will need to be made on a day to day basis in order to avoid relapse, and treatment and support (for example, through a mix of professional help, and support groups) may need to be ongoing for months, or even years. People can and do recover from anorexia, provided the person wants to get better; with the right support, and with patience and commitment, prospects for long-term physical and emotional recovery are good.