Anorexia nervosa (AN) is characterized by a severe disturbance in eating behavior as well as an underlying psychological profile that is as important to the disorder as the disturbed eating behavior. Individuals with AN are underweight yet fear gaining weight and also exhibit disturbances in the perception of the shape and size of their bodies. In addition, they exhibit psychological characteristics such as identity disturbance, perfectionism, and low self-esteem despite their often exceptionally high levels of performance in various spheres. A variety of physical, psychological, and psychosocial complications can arise as a result of this disorder. Several treatment options are available to individuals with AN, including interpersonal, cognitive-behavioral, group, and family therapies, as well as pharmacological treatments.
Characteristics And Symptoms
In order to be diagnosed with AN, individuals must exhibit each of the following:
- Severely reduced weight (e.g., weight less than 85% of expected weight for age and height)
- Intense fears of gaining weight
- Disturbed experience of body weight or shape, or denial of the seriousness of the current low body weight
- For women, the absence of at least three menstrual cycles (amenorrhea)
There are two subtypes of AN: binge-eating and purging type, and restricting type. Individuals with AN binge-eating and purging type regularly engage in binge-eating or purging behavior. In contrast, individuals with AN restricting type do not regularly engage in binge-eating or purging behavior. Binge-eating involves feeling out of control while eating a large amount of food in a discrete period of time, and purging behavior includes self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Physical And Medical Complications
Many of the physical and medical complications associated with AN arise as a result of the semi starvation state that characterizes this disorder. These complications include emaciation, cold intolerance, osteoporosis, anemia, low blood pressure (hypotension), slow heart rate (bradycardia), and the development of a fine, downy body hair (lanugo). Erosion of dental enamel and other dental problems may also occur in individuals who use vomiting as a means of weight control.
Many individuals with AN exhibit depressed mood, social withdrawal, insomnia, and other depressive symptoms. These symptoms may be the result of being in a semi starvation state; hence, mood disturbances may disappear after weight gain, although those that were present before weight loss often persist. Obsessive thoughts and compulsive behaviors concerning food are common and also may be associated with a lack of proper nutrition (although obsessive-compulsive features unrelated to food, body shape, or weight also may occur).
Irritability, loss of sexual libido, and reduced concentration are other features that may occur in individuals with AN. These psychological consequences, in addition to the physical and medical complications associated with AN, negatively affect the quality of life of individuals with AN.
For females, the lifetime prevalence of AN is about 0.5%. AN occurs about 10 times more frequently in females than in males. The onset of AN typically occurs during middle to late adolescence (14 to 18 years). AN seems to be more prevalent in industrialized societies in which food is abundant, including the United States, Canada, Europe, Australia, Japan, and South Africa. The incidence of AN has increased over the past several decades; however, it is not clear whether this merely reflects an increased awareness of AN or whether the true incidence of this disorder is increasing.
Development Of Anorexia Nervosa
A biopsychosocial perspective has been employed to describe the factors that may contribute to the development of AN. This perspective implicates cultural, familial, biological, social, cognitive, and other factors in the development and maintenance of AN. These factors are outlined below.
The idealization of thinness that exists in Western society is thought to contribute to the development of AN. The “thin ideal” tends to exist in cultures in which there is an abundance of food. Furthermore, the idealization of thinness is targeted more at females than males.
Compared with the families of individuals with no eating disorders, the families of anorexic individuals are more rigid in their organization and typically avoid discussing disagreements between parents and children. However, it could be that these factors are a consequence of having a family member with AN, rather than a cause of the disorder itself.
There is also evidence that suggests eating disorders occur more often among the first-degree relatives of individuals with AN, as compared with the relatives of individuals without eating disorders. This may reflect genetic or environmental transmission of AN.
Individual Risk Factors
Personality and Trait Characteristics
Individuals with AN tend to be perfectionistic and have low self-esteem. Hilde Bruch, an influential contributor to the literature on etiology and psychotherapy for AN, suggested that individuals with AN are struggling for autonomy, control, and self-respect and that the changes in eating behaviors that occur with AN represent attempts to overcome this struggle. The use of weight and shape as a means of self-evaluation, identity formation, and control appears to be a key factor in the development and maintenance of AN.
Body dissatisfaction in and of itself is unlikely to lead to the development of AN. However, if an individual with high body dissatisfaction seizes upon weight and shape as a means of self-control, extreme dieting behaviors may ensue, which in turn may contribute to the development of AN in susceptible individuals (who also have the personality and familial risk factors).
Neuroendocrine functioning is altered in individuals with AN. Serotonin imbalance has been implicated as a cause of AN, although it remains unclear whether this imbalance is present before the development of AN, or whether it may be a consequence of the disorder.
Negative interpersonal experiences, including trauma and abuse, have also been implicated in the development of AN. It may be that individuals who experience these stressful life events develop AN as a coping mechanism in order to attempt to regain emotional control and overcome identity problems.
People with AN often fail to recognize or admit that they are ill. As a result, they may resist treatment. Many individuals with AN present for treatment in order to satisfy their loved ones who pressure them to seek treatment out of concern. Once in treatment, AN patients may fail to comply with treatment requirements and may be uncooperative with clinicians.
Because of the complexity and severity of the disorder, individuals with AN require a comprehensive treatment plan, including medical care, psychosocial interventions, nutritional counseling, and, when indicated, medication management. When a clinician diagnoses an individual with AN, the clinician must determine whether the person is in immediate physical danger and thus requires hospitalization. Treatment of AN typically involves three main components: (1) restoring weight to a minimally healthy level; (2) treating psychological disturbances such as body shape or weight distortion, low self-esteem, and interpersonal conflicts; and (3) relapse prevention (maintaining treatment gains).
Patients with AN may require hospitalization for the purpose of medical management or active treatment of the eating disorder. Severity of weight loss is the major criterion used to indicate that admission is required. When weight is at or below 75% of what is expected for the person’s age and height, hospitalization is usually recommended. Inpatient programs typically involve several elements, including nutritional and medical rehabilitation and psychotherapy. Patients are encouraged or required to eat regular meals. In addition to these meals, patients may be required to take nutritional supplements. There is considerable controversy as to the appropriateness of feeding patients against their wishes. Admissions for involuntary feeding are considered to be an emergency measure. Patients admitted under these circumstances are not considered to be actively pursuing treatment. AN patients may also receive individual or group therapy addressing their psychological disturbances. Inpatients with AN progress to outpatient treatment when it is considered safe for them to do so.
Unfortunately, limited psychotherapy outcome data exist for the treatment of AN. The data that are available fail to indicate which type of treatment is best. However, several types of psychotherapy are available:
- Cognitive-behavioral therapy includes behavioral elements (including the normalization of eating) with a focus on identifying and altering dysfunctional thought patterns, attitudes, and beliefs, which may trigger and perpetuate restrictive eating and binge eating and purging behavior. Self-monitoring of food intake and symptoms is also important, as is identifying triggers and developing alternative reactions to them.
- Interpersonal psychotherapy focuses on relationship difficulties, self-esteem, assertiveness, social skills, and coping strategies.
- There is no one unified form of family therapy. The goal of family therapy is to help members of the family change behaviors that may have contributed to the development and maintenance of the eating disorder.
- Group psychotherapy can be very helpful because it provides people with AN with the opportunity to share their experiences and to give feedback to each other, and it may enhance self-esteem through helping others. Groups are usually led by one or two facilitators.
No specific medications have been shown to treat AN effectively. However, some medications may be helpful in speeding up recovery or in treating associated problems such as anxiety and depression. Antidepressant medications may help in reducing depressive feelings, as well as controlling obsessive thoughts about food and weight.
Course and Prognosis
The mortality rate among people with AN is estimated at 0.59% per year, which is about three times higher than for other psychiatric illness. The most common causes of death are complications of the disorder, such as cardiac arrest or electrolyte imbalance, and suicide. The course and outcome of AN vary. Of those individuals who survive, about 46% fully recover, 33% experience some improvement, and 20% remain chronically ill. A number of individuals with AN later develop other eating disorders, particularly bulimia nervosa. One study found that 16.8% of AN patients went on to meet diagnostic criteria for bulimia over the course of a 6-year follow-up period.
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