Anorexia Nervosa

Basic Information

Anorexia nervosa is a serious, sometimes life-threatening, eating disorder that primarily affects women at a ratio thought to be 20 to 1 female to male. Even though we have seen an increase in this illness during the last 5 decades, most likely tied to society's perception about weight and physical appearance, it remains a rare illness affecting only 1 percent of the U.S. population, i.e. approximately 5 to 10 cases for every 100,000 persons. Most at risk are teenage girls with the average onset of this illness at 17 years. Also, it seems to affect women or girls in higher rather than lower social and economic classes. African Americans and Hispanics are less affected by this condition than Caucasians. Those most especially vulnerable seem to be in professions or leisure time activities where a thin figure is expected and even glorified. Models, ballet dancers, gymnasts and figure skaters are examples. Hence almost all of these women are thin to begin with but do not perceive themselves as being underweight and feel they must continue to lose weight, often by exhibiting binge-and-purge eating habits. But unlike bulimia, in which the binge/purge syndrome characterizes the illness, anorexia nervosa is more accurately characterized as self-starvation. Even in the face of dire health consequences that can occur when weight is rapidly lost or too low a body weight is maintained, the patient's deep-rooted fear of weight gain or being fat precludes her from seeing reality. This is a dangerous situation because the mortality rate for anorexia nervosa stands at 20 percent, one of the highest mortality levels in any of the personality or psychiatric disorders.

The causes of this illness are not known however there are known risk factors that are cultural, psychological, genetic and social, both familial and societal. They include:

sexual abuse (found in approximately 50% of patients)
a suspected genetic link from parent to child
mothers who are perfectionistic and overprotective with few boundaries and fathers who are distant, absent, the more passive of the two parents and often workaholics
messages in American culture that thin is beautiful and self-image must conform to this concept makes getting self-esteem from other sources virtually non-existent

The anorectic child is generally submissive, docile and does not have a voice separate from the dominant parent so does not go through the usual rebellious stage which usually occurs around 2 years old. As the child nears adolescence anorexia nervosa begins to develop and is thought to be a silent, active rebellion and disruption. Sexual maturity is often physically delayed because of the disease and sexual feelings and normal development are often delayed because of fears of pregnancy, menstruation and even fear of the sex act itself.

Symptoms

A patient with anorexia nervosa will present both psychological and physical symptoms. An experienced health care provider will usually be able to perceive the patient's very rigid demeanor and polite, short responses to questions. The anorectic's over-controlled behavior contrasts sharply with the bulimic's lack of self control often exhibited by shoplifting, substance abuse, alcoholism and suicide attempts.

Physical symptoms may include:

emaciation
dry skin or yellowing skin
thinning scalp
hard, brittle nails
no sign of normal fat distribution on the body
low blood pressure
abnormal heart rate
low potassium
dehydration
anemia
constipation
bone disease

Finally a strong denial from the patient about weight loss or realistic body weight evaluation is a key towards diagnosis.

Diagnosis/Treatment

An early diagnosis is helpful in treating this disorder. When weight loss cannot be explained by another illness, especially in young girls, anorexia nervosa should be considered as a possible cause. An experienced health care provider will look for signs of the symptoms described above and especially look for signs presented by later stage anorectics which include emaciation, thin and dry skin and hypothermia as well as constipation. Patients with this illness often resist and resent treatment and the more severe the disease the worse the prognosis. In mild cases patients will respond to nutritional counseling and the inevitable consequences of self-starvation. But in severe cases the resistance is quite high to accepting their condition as a real disease. Hence a management team of nutritionists, psychiatrists and physicians must work carefully in education and follow-up for the patient. Hospitalization is required for many patients and 50% of patients who receive hospital treatment again require hospitalization within that same year.

A weight history of the patient is an important diagnostic tool. A dietary history should lead to diagnosis as well. Because of physical problems related to this illness, a complete physical exam and laboratory work should be administered to the patient.

Many health care providers consider this illness a family illness where there are feelings of guilt and shame, and dysfunction may be occurring on some level. Thus the patient and her family must understand the dangers of self-starvation and understand how to give and get emotional support with nutritional therapy and weight stabilization the recognized goal. A patient must learn to control eating behaviors, shop carefully for food and not to eat alone. It is important also for the patient to learn not to buy clothes that she has to lose weight to fit into but to purchase clothes that already fit. In many cases since this is a very dangerous life-threatening illness patients are referred to treatment units that are experienced treating this disease.

If you feel you have or are at risk for anorexia nervosa please see your health care provider promptly.