"Anorexia" and "Anorexic" redirect here. For the medication, see Anorectic. For other uses, see Anorexia (disambiguation).
|"Miss A—" pictured in 1866 and in 1870 after treatment. She was one of the earliest case studies of anorexia. From the published medical papers of Sir William Gull|
|Symptoms||Low weight, fear of gaining weight, strong desire to be thin, food restrictions|
|Complications||Osteoporosis, infertility, heart damage|
|Usual onset||Teen years to young adulthood|
|Risk factors||Family history, high-level athletics, modelling, dancing|
|Similar conditions||Body dysmorphic disorder, bulimia nervosa, substance use disorder, hyperthyroidism, inflammatory bowel disease, dysphagia, cancer|
|Treatment||Cognitive behavioral therapy, hospitalisation to restore weight|
|Prognosis||5% risk of death over 10 years|
|Frequency||2.9 million (2015)|
[edit on Wikidata]
Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, fear of gaining weight, and a strong desire to be thin, resulting in food restriction. Many people with anorexia see themselves as overweight even though they are in fact underweight. If asked they usually deny they have a problem with low weight. Often they weigh themselves frequently, eat only small amounts, and only eat certain foods. Some will exercise excessively, force themselves to vomit, or use laxatives to produce weight loss. Complications may include osteoporosis, infertility and heart damage, among others. Women will often stop having menstrual periods.
The cause is not known. There appear to be some genetic components with identical twins more often affected than non-identical twins. Cultural factors also appear to play a role with societies that value thinness having higher rates of disease. Additionally, it occurs more commonly among those involved in activities that value thinness such as high-level athletics, modelling, and dancing. Anorexia often begins following a major life-change or stress-inducing event. The diagnosis requires a significantly low weight. The severity of disease is based on body mass index (BMI) in adults with mild disease having a BMI of greater than 17, moderate a BMI of 16 to 17, severe a BMI of 15 to 16, and extreme a BMI less than 15. In children a BMI for age percentile of less than the 5th percentile is often used.
Treatment of anorexia involves restoring a healthy weight, treating the underlying psychological problems, and addressing behaviors that promote the problem. While medications do not help with weight gain, they may be used to help with associated anxiety or depression. A number of types of therapy may be useful including an approach where parents assume responsibility for feeding their child, known as Maudsley family therapy and cognitive behavioral therapy. Sometimes people require admission to hospital to restore weight. Evidence for benefit from nasogastric tube feeding, however, is unclear. Some people will just have a single episode and recover while others may have many episodes over years. Many complications improve or resolve with regaining of weight.
Globally, anorexia is estimated to affect 2.9 million people as of 2015. It is estimated to occur in 0.9% to 4.3% of women and 0.2% to 0.3% of men in Western countries at some point in their life. About 0.4% of young women are affected in a given year and it is estimated to occur ten times less commonly in men. Rates in most of the developing world are unclear. Often it begins during the teen years or young adulthood. While anorexia became more commonly diagnosed during the 20th century it is unclear if this was due to an increase in its frequency or simply better diagnosis. In 2013 it directly resulted in about 600 deaths globally, up from 400 deaths in 1990. Eating disorders also increase a person's risk of death from a wide range of other causes, including suicide. About 5% of people with anorexia die from complications over a ten-year period, a nearly 6 times increased risk. The term anorexia nervosa was first used in 1873 by William Gull to describe this condition.
Signs and symptoms
Anorexia nervosa is an eating disorder characterized by attempts to lose weight, to the point of starvation. A person with anorexia nervosa may exhibit a number of signs and symptoms, the type and severity of which may vary and may be present but not readily apparent.
Anorexia nervosa, and the associated malnutrition that results from self-imposed starvation, can cause complications in every major organ system in the body.Hypokalaemia, a drop in the level of potassium in the blood, is a sign of anorexia nervosa. A significant drop in potassium can cause abnormal heart rhythms, constipation, fatigue, muscle damage and paralysis.
Symptoms may include:
- A low body mass index for one's age and height.
- Amenorrhea, a symptom that occurs after prolonged weight loss; causes menstruation to stop, hair becomes brittle, and skin becomes yellow and unhealthy.
- Fear of even the slightest weight gain; taking all precautionary measures to avoid weight gain or becoming "overweight".
- Rapid, continuous weight loss.
- Lanugo: soft, fine hair growing over the face and body.
- An obsession with counting calories and monitoring fat contents of food.
- Preoccupation with food, recipes, or cooking; may cook elaborate dinners for others, but not eat the food themselves or consume a very small portion.
- Food restrictions despite being underweight or at a healthy weight.
- Food rituals, such as cutting food into tiny pieces, refusing to eat around others and hiding or discarding of food.
- Purging: May use laxatives, diet pills, ipecac syrup, or water pills to flush food out of their system after eating or may engage in self-induced vomiting though this is a more common symptom of bulimia.
- Excessive exercise including micro-exercising, for example making small persistent movements of fingers or toes.
- Perception of self as overweight, in contradiction to an underweight reality.
- Intolerance to cold and frequent complaints of being cold; body temperature may lower (hypothermia) in an effort to conserve energy due to malnutrition.
- Hypotension or orthostatic hypotension.
- Bradycardia or tachycardia.
- Depression, anxiety disorders and insomnia.
- Solitude: may avoid friends and family and become more withdrawn and secretive.
- Abdominal distension.
- Halitosis (from vomiting or starvation-induced ketosis).
- Dry hair and skin, as well as hair thinning.
- Chronic fatigue.
- Rapid mood swings.
- Having feet discoloration causing an orange appearance.
- Having severe muscle tension + aches and pains.
- Evidence/habits of self harming or self-loathing.
- Admiration of thinner people.
Interoception has an important role in homeostasis and regulation of emotions and motivation. Anorexia has been associated with disturbances to interoception. People with anorexia concentrate on distorted perceptions of their body exterior due to fear of looking overweight. Aside from outer appearance, they also report abnormal bodily functions such as indistinct feelings of fullness. This provides an example of miscommunication between body and brain. Further, people with anorexia experience abnormally intense cardiorespiratory sensations, particularly of the breath, most prevalent before they consume a meal. People with anorexia also report inability to distinguish emotions from bodily sensations in general, called alexithymia. In addition to metacognition, people with anorexia also have difficultly with social cognition including interpreting other’s emotions, and demonstrating empathy. Abnormal interoceptive awareness like these examples have been observed so frequently in anorexia that they have become key characteristics of the illness.
Other psychological issues may factor into anorexia nervosa; some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Some people have a previous disorder which may increase their vulnerability to developing an eating disorder and some develop them afterwards.[medical citation needed] The presence of Axis I or Axis II psychiatric comorbidity has been shown to affect the severity and type of anorexia nervosa symptoms in both adolescents and adults.[medical citation needed]
Obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) are highly comorbid with AN, particularly the restrictive subtype. Obsessive-compulsive personality disorder is linked with more severe symptomatology and worse prognosis. The causality between personality disorders and eating disorders has yet to be fully established.[medical citation needed] Other comorbid conditions include depression,alcoholism,borderline and other personality disorders,anxiety disorders,attention deficit hyperactivity disorder, and body dysmorphic disorder (BDD). Depression and anxiety are the most common comorbidities, and depression is associated with a worse outcome.
Autism spectrum disorders occur more commonly among people with eating disorders than in the general population. Zucker et al. (2007) proposed that conditions on the autism spectrum make up the cognitive endophenotype underlying anorexia nervosa and appealed for increased interdisciplinary collaboration.
There is evidence for biological, psychological, developmental, and sociocultural risk factors, but the exact cause of eating disorders is unknown.
Anorexia nervosa is highly heritable. Twin studies have shown a heritability rate of between 28 and 58%. First degree relative of those with anorexia have roughly 12 times the risk of developing anorexia.Association studies have been performed, studying 128 different polymorphisms related to 43 genes including genes involved in regulation of eating behavior, motivation and reward mechanics, personality traits and emotion. Consistent associations have been identified for polymorphisms associated with agouti-related peptide, brain derived neurotrophic factor, catechol-o-methyl transferase, SK3 and opioid receptor delta-1.Epigenetic modifications, such as DNA methylation, may contribute to the development or maintenance of anorexia nervosa, though clinical research in this area is in its infancy.
Obstetric complications: prenatal and perinatal complications may factor into the development of anorexia nervosa, such as maternal anemia, diabetes mellitus, preeclampsia, placental infarction, and neonatalcardiac abnormalities. Neonatal complications may also have an influence on harm avoidance, one of the personality traits associated with the development of AN.[medical citation needed]
Neuroendocrine dysregulation: altered signalling of peptides that facilitate communication between the gut, brain and adipose tissue, such as ghrelin, leptin, neuropeptide Y and orexin, may contribute to the pathogenesis of anorexia nervosa by disrupting regulation of hunger and satiety.
Gastrointestinal diseases: people with gastrointestinal disorders may be more risk of developing disorders eating practices than the general population, principally restrictive eating disturbances. An association of anorexia nervosa with celiac disease has been found. The role that gastrointestinal symptoms play in the development of eating disorders seems rather complex. Some authors report that unresolved symptoms prior to gastrointestinal disease diagnosis may create a food aversion in these persons, causing alterations to their eating patterns. Other authors report that greater symptoms throughout their diagnosis led to greater risk. It has been documented that some people with celiac disease, irritable bowel syndrome or inflammatory bowel disease who are not conscious about the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods. Some authors suggest that medical professionals should evaluate the presence of an unrecognized celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders, especially in women.
Studies have hypothesized the continuance of disordered eating patterns may be epiphenomena of starvation. The results of the Minnesota Starvation Experiment showed normal controls exhibit many of the behavioral patterns of anorexia nervosa (AN) when subjected to starvation. This may be due to the numerous changes in the neuroendocrine system, which results in a self-perpetuating cycle.
Another hypothesis is that anorexia nervosa is more likely to occur in populations in which obesity is more prevalent, and results from a sexually selected evolutionary drive to appear youthful in populations in which size becomes the primary indicator of age.[unreliable medical source?]
Anorexia nervosa is more likely to occur in a person's pubertal years. Some explanatory hypotheses for the rising prevalence of eating disorders in adolescence are "increase of adipose tissue in girls, hormonal changes of puberty, societal expectations of increased independence and autonomy that are particularly difficult for anorexic adolescents to meet; [and] increased influence of the peer group and its values." 
Early theories of the cause of anorexia linked it to childhood sexual abuse or dysfunctional families; evidence is conflicting, and well-designed research is needed. The fear of food is known as sitiophobia,cibophobia, or sitophobia and is part of the differential diagnosis. Other psychological causes of anorexia include low self-esteem, feeling like there is lack of control, depression, anxiety, and loneliness.
Anorexia nervosa has been increasingly diagnosed since 1950; the increase has been linked to vulnerability and internalization of body ideals. People in professions where there is a particular social pressure to be thin (such as models and dancers) were more likely to develop anorexia,[medical citation needed] and those with anorexia have much higher contact with cultural sources that promote weight loss.[medical citation needed] This trend can also be observed for people who partake in certain sports, such as jockeys and wrestlers. There is a higher incidence and prevalence of anorexia nervosa in sports with an emphasis on aesthetics, where low body fat is advantageous, and sports in which one has to make weight for competition. Family dynamics can play big part in the cause of anorexia. When there is a constant pressure from people to be thin, teasing, bullying can cause low self-esteem and other psychological symptoms.
Constant exposure to media that presents body ideals may constitute a risk factor for body dissatisfaction and anorexia nervosa. The cultural ideal for body shape for men versus women continues to favor slender women and athletic, V-shaped muscular men. A 2002 review found that, of the magazines most popular among people aged 18 to 24 years, those read by men, unlike those read by women, were more likely to feature ads and articles on shape than on diet.[unreliable medical source?] Body dissatisfaction and internalization of body ideals are risk factors for anorexia nervosa that threaten the health of both male and female populations.[medical citation needed]
Websites that stress the importance of attainment of body ideals extol and promote anorexia nervosa through the use of religious metaphors, lifestyle descriptions, "thinspiration" or "fitspiration" (inspirational photo galleries and quotes that aim to serve as motivators for attainment of body ideals). Pro-anorexia websites reinforce internalization of body ideals and the importance of their attainment.
The media give men and women a false view of what people truly look like. In magazines, movies and even on billboards most of the actors/models are photoshopped in multiple ways. People then strive to look like these "perfect" role models when in reality they aren't any where near perfection themselves.
Evidence from physiological, pharmacological and neuroimaging studies suggest serotonin may play a role in anorexia. While acutely ill, metabolic changes may produce a number of biological findings in people with anorexia that are not necessarily causative of the anorexic behavior. For example, abnormal hormonal responses to challenges with serotonergic agents have been observed during acute illness, but not recovery. Nevertheless, increased cerebrospinal fluid concentrations of 5-Hydroxyindoleacetic acid(a metabolite of serotonin), and changes in anorectic behavior in response to tryptophan depletion(a metabolic precursor to serotonin) support a role in anorexia. The binding potential of 5-HT2A receptors and 5-HT1A receptors have been reportedly decreased and increased respectively in a number of cortical regions. While these findings may be confounded by comorbid psychiatric disorders, taken as a whole they indicate serotonin in anorexia. These alterations in serotonin have been linked to traits characteristic of anorexia such as obsessiveness, anxiety, and appetite dysregulation.
Neuroimaging studies investigating the functional connectivity between brain regions have observed a number of alterations in networks related to cognitive control, introspection, and sensory function. Alterations in networks relate to the dorsal anterior cingulate cortex may be related to excessive cognitive control of eating related behaviors. Similarly, altered somatosensory integration and introspection may relate to abnormal body image. A review of functional neuroimaging studies reported reduced activations in "bottom up" limbic region and increased activations in "top down" cortical regions which may play a role in restrictive eating.
Compared to controls, recovered anorexics show reduced activation in the reward system in response to food, and reduced correlation between self reported liking of a sugary drink and activity in the striatum and ACC. Increased binding potential of raclopride in the striatum, interpreted as decreased endogenous dopamine has also been observed.
Structural neuroimaging studies have found global reductions in both gray matter and white matter, as well as increased cerebrospinal fluid volumes. Regional decreases in the left hypothalamus, left inferior parietal lobe, right lentiform nucleus and right caudate have also been reported. A number of studies report increased orbitofrontal cortex volume in anorexia, although findings are inconsistent. Reduced white matter integrity in the fornix has also been reported.
A diagnostic assessment includes the person's current circumstances, biographical history, current symptoms, and family history. The assessment also includes a mental state examination, which is an assessment of the person's current mood and thought content, focusing on views on weight and patterns of eating.
Anorexia nervosa is classified under the Feeding and Eating Disorders in the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5).
Relative to the previous version of the DSM (DSM-IV-TR), the 2013 revision (DSM5) reflects changes in the criteria for anorexia nervosa, most notably that of the amenorrhea criterion being removed. Amenorrhea was removed for several reasons: it does not apply to males, it is not applicable for females before or after the age of menstruation or taking birth control pills, and some women who meet the other criteria for AN still report some menstrual activity.
There are two subtypes of AN:
- Binge-eating/purging type: the individual utilizes binge eating or displays purging behavior as a means for losing weight. It is different from bulimia nervosa in terms of the individual's weight. An individual with binge-eating/purging type anorexia can maintain a healthy or normal weight, but is usually significantly underweight. People with bulimia nervosa on the other hand can sometimes be overweight.
- Restricting type: the individual uses restricting food intake, fasting, diet pills, or exercise as a means for losing weight; they may exercise excessively to keep off weight or prevent weight gain, and some individuals eat only enough to stay alive.
Levels of severity
Body mass index (BMI) is used by the DSM-5 as an indicator of the level of severity of anorexia nervosa. The DSM-5 states these as follows:
- Mild: BMI of greater than 17
- Moderate: BMI of 16–16.99
- Severe: BMI of 15–15.99
- Extreme: BMI of less than 15
Medical tests to check for signs of physical deterioration in anorexia nervosa may be performed by a general physician or psychiatrist, including:
- Complete Blood Count (CBC): a test of the white blood cells, red blood cells and platelets used to assess the presence of various disorders such as leukocytosis, leukopenia, thrombocytosis and anemia which may result from malnutrition.
- Urinalysis: a variety of tests performed on the urine used in the diagnosis of medical disorders, to test for substance abuse, and as an indicator of overall health
- Chem-20: Chem-20 also known as SMA-20 a group of twenty separate chemical tests performed on blood serum. Tests include cholesterol, protein and electrolytes such as potassium, chlorine and sodium and tests specific to liver and kidney function.
- Glucose tolerance test: Oral glucose tolerance test (OGTT) used to assess the body's ability to metabolize glucose. Can be useful in detecting various disorders such as diabetes, an insulinoma, Cushing's Syndrome, hypoglycemia and polycystic ovary syndrome.
- Serumcholinesterase test: a test of liver enzymes (acetylcholinesterase and pseudocholinesterase) useful as a test of liver function and to assess the effects of malnutrition.
- Liver Function Test: A series of tests used to assess liver function some of the tests are also used in the assessment of malnutrition, protein deficiency, kidney function, bleeding disorders, and Crohn's Disease.
- Lh response to GnRH: Luteinizing hormone (Lh) response to gonadotropin-releasing hormone (GnRH): Tests the pituitary glands' response to GnRh a hormone produced in the hypothalamus. Hypogonadism is often seen in anorexia nervosa cases.
- Creatine Kinase Test (CK-Test): measures the circulating blood levels of creatine kinase an enzyme found in the heart (CK-MB), brain (CK-BB) and skeletal muscle (CK-MM).
- Blood urea nitrogen (BUN) test: urea nitrogen is the byproduct of protein metabolism first formed in the liver then removed from the body by the kidneys. The BUN test is primarily used to test kidney function. A low BUN level may indicate the effects of malnutrition.
- BUN-to-creatinine ratio: A BUN to creatinine ratio is used to predict various conditions. A high BUN/creatinine ratio can occur in severe hydration, acute kidney failure, congestive heart failure, and intestinal bleeding. A low BUN/creatinine ratio can indicate a low protein diet, celiac disease, rhabdomyolysis, or cirrhosis of the liver.
- Electrocardiogram (EKG or ECG): measures electrical activity of the heart. It can be used to detect various disorders such as hyperkalemia
- Electroencephalogram (EEG): measures the electrical activity of the brain. It can be used to detect abnormalities such as those associated with pituitary tumors.
- Thyroid Screen TSH, t4, t3 :test used to assess thyroid functioning by checking levels of thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3)
Main article: Anorexia nervosa (differential diagnoses)
A variety of medical and psychological conditions have been misdiagnosed as anorexia nervosa; in some cases the correct diagnosis was not made for more than ten years.
The distinction between the diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make as there is considerable overlap between people diagnosed with these conditions. Seemingly minor changes in a people's overall behavior or attitude can change a diagnosis from anorexia: binge-eating type to bulimia nervosa. A main factor differentiating binge-purge anorexia from bulimia is the gap in physical weight. Someone with bulimia nervosa is ordinarily at a healthy weight, or slightly overweight. Someone with binge-purge anorexia is commonly underweight. People with the binge-purging subtype of AN may be significantly underweight and typically do not binge-eat large amounts of food, yet they purge the small amount of food they eat. In contrast, those with bulimia nervosa tend to be at normal weight or overweight and binge large amounts of food. It is not unusual for a person with an eating disorder to "move through" various diagnoses as their behavior and beliefs change over time.
There is no conclusive evidence that any particular treatment for anorexia nervosa works better than others; however, there is enough evidence to suggest that early intervention and treatment are more effective. Treatment for anorexia nervosa tries to address three main areas.
- Restoring the person to a healthy weight;
- Treating the psychological disorders related to the illness;
- Reducing or eliminating behaviours or thoughts that originally led to the disordered eating.
Although restoring the person's weight is the primary task at hand, optimal treatment also includes and monitors behavioral change in the individual as well. There is some evidence that hospitalisation might adversely affect long term outcome.
Psychotherapy for individuals with AN is challenging as they may value being thin and may seek to maintain control and resist change. Some studies demonstrate that family based therapy in adolescents with AN is superior to individual therapy.
Treatment of people with AN is difficult because they are afraid of gaining weight. Initially developing a desire to change may be important.
Diet is the most essential factor to work on in people with anorexia nervosa, and must be tailored to each person's needs. Food variety is important when establishing meal plans as well as foods that are higher in energy density. People must consume adequate calories, starting slowly, and increasing at a measured pace. Evidence of a role for zinc supplementation during refeeding is unclear.
Family-based treatment (FBT) has been shown to be more successful than individual therapy for adolescents with AN. Various forms of family-based treatment have been proven to work in the treatment of adolescent AN including conjoint family therapy (CFT), in which the parents and child are seen together by the same therapist, and separated family therapy (SFT) in which the parents and child attend therapy separately with different therapists. Proponents of Family therapy for adolescents with AN assert that it is important to include parents in the adolescent's treatment.
A four- to five-year follow up study of the Maudsley family therapy, an evidence-based manualized model, showed full recovery at rates up to 90%. Although this model is recommended by the NIMH, critics claim that it has the potential to create power struggles in an intimate relationship and may disrupt equal partnerships.[medical citation needed]
Cognitive behavioral therapy (CBT) is useful in adolescents and adults with anorexia nervosa;acceptance and commitment therapy is a type of CBT, which has shown promise in the treatment of AN.Cognitive remediation therapy (CRT) is used in treating anorexia nervosa.
Pharmaceuticals have limited benefit for anorexia itself.
Admission to hospital
AN has a high mortality and patients admitted in a severely ill state to medical units are at particularly high risk. Diagnosis can be challenging, risk assessment may not be performed accurately, consent and the need for compulsion may not be assessed appropriately, refeeding syndrome may be missed or poorly treated and the behavioural and family problems in AN may be missed or poorly managed. The MARSIPAN guidelines recommend that medical and psychiatric experts work together in managing severely ill people with AN.
The rate of refeeding can be difficult to establish, because the fear of refeeding syndrome (RFS) can lead to underfeeding. It is thought that RFS, with falling phosphate and potassium levels, is more likely to occur when BMI is very low, and when medical comorbidities such as infection or cardiac failure, are present. In those circumstances, it is recommended to start refeeding slowly but to build up rapidly as long as RFS does not occur. Recommendations on energy requirements vary, from 5–10 kCal/Kg/day in the most medically compromised patients, who appear to have the highest risk of RFS to 1900 Kcal/day
AN has the highest mortality rate of any psychological disorder. The mortality rate is 11 to 12 times greater than in the general population, and the suicide risk is 56 times higher. Half of women with AN achieve a full recovery, while an additional 20–30% may partially recover. Not all people with anorexia recover completely: about 20% develop anorexia nervosa as a chronic disorder. If anorexia nervosa is not treated, serious complications such as heart conditions and kidney failure can arise and eventually lead to death. The average number of years from onset to remission of AN is seven for women and three for men. After ten to fifteen years, 70% of people no longer meet the diagnostic criteria, but many still continue to have eating-related problems.
Alexithymia influences treatment outcome. Recovery is also viewed on a spectrum rather than black and white. According to the Morgan-Russell criteria, individuals can have a good, intermediate, or poor outcome. Even when a person is classified as having a "good" outcome, weight only has to be within 15% of average, and normal menstruation must be present in females. The good outcome also excludes psychological health. Recovery for people with anorexia nervosa is undeniably positive, but recovery does not mean a return to normal.[medical citation needed]
Anorexia nervosa can have serious implications if its duration and severity are significant and if onset occurs before the completion of growth, pubertal maturation, or the attainment of peak bone mass.[medical citation needed] Complications specific to adolescents and children with anorexia nervosa can include the following: Growth retardation may occur, as height gain may slow and can stop completely with severe weight loss or chronic malnutrition. In such cases, provided that growth potential is preserved, height increase can resume and reach full potential after normal intake is resumed.[medical citation needed] Height potential is normally preserved if the duration and severity of illness are not significant or if the illness is accompanied by delayed bone age (especially prior to a bone age of approximately 15 years), as hypogonadism may partially counteract the effects of undernutrition on height by allowing for a longer duration of growth compared to controls.[medical citation needed] Appropriate early treatment can preserve height potential, and may even help to increase it in some post-anorexic subjects, due to factors such as long-term reduced estrogen-producing adipose tissue levels compared to premorbid levels.[medical citation needed] In some cases, especially where onset is before puberty, complications such as stunted growth and pubertal delay are usually reversible.
Anorexia nervosa causes alterations in the female reproductive system; significant weight loss, as well as psychological stress and intense exercise, typically results in a cessation of menstruation in women who are past puberty. In patients with anorexia nervosa, there is a reduction of the secretion of gonadotropin releasing hormone in the central nervous system, preventing ovulation. Anorexia nervosa can also result in pubertal delay or arrest. Both height gain and pubertal development are dependent on the release of growth hormone and gonadotrophins (LH and FSH) from the pituitary gland. Suppression of gonadotrophins in people with anorexia nervosa has been documented. Typically, growth hormone (GH) levels are high, but levels of IGF-1, the downstream hormone that should be released in response to GH are low; this indicates a state of “resistance” to GH due to chronic starvation. IGF-1 is necessary for bone formation, and decreased levels in anorexia nervosa contribute to a loss of bone density and potentially contribute to osteopenia or osteoporosis. Anorexia nervosa can also result in reduction of peak bone mass. Buildup of bone is greatest during adolescence, and if onset of anorexia nervosa occurs during this time and stalls puberty, low bone mass may be permanent.
Hepatic steatosis, or fatty infiltration of the liver, can also occur, and is an indicator of malnutrition in children. Neurological disorders that may occur as complications include seizures and tremors. Wernicke encephalopathy, which results from vitamin B1 deficiency, has been reported in patients who are extremely malnourished; symptoms include confusion, problems with the muscles responsible for eye movements and abnormalities in walking gait.
The most common gastrointestinal complications of anorexia nervosa are delayed stomach emptying and constipation, but also include elevated liver function tests, diarrhea, acute pancreatitis, heartburn, difficulty swallowing, and, rarely, superior mesenteric artery syndrome. Delayed stomach emptying, or gastroparesis, often develops following food restriction and weight loss; the most common symptom is bloating with gas and abdominal distension, and often occurs after eating. Other symptoms of gastroparesis include early satiety, fullness, nausea, and vomiting. The symptoms may inhibit efforts at eating and recovery, but can be managed by limiting high-fiber foods, using liquid nutritional supplements, or using metoclopramide to increase emptying of food from the stomach. Gastroparesis generally resolves when weight is regained.
Anorexia nervosa increases the risk of sudden cardiac death, though the precise cause is unknown. Cardiac complications include structural and functional changes to the heart. Some of these cardiovascular changes are mild and are reversible with treatment, while others may be life-threatening. Cardiac complications can include arrhythmias, abnormally slow heart beat, low blood pressure, decreased size of the heart muscle, reduced heart volume, mitral valve prolapse, myocardial fibrosis, and pericardial effusion.
Abnormalities in conduction and repolarization of the heart that can result from anorexia nervosa include QT prolongation, increased QT dispersion, conduction delays, and junctional escape rhythms. Electrolyte abnormalities, particularly hypokalemia and hypomagnesemia
Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states...Read More
In August of 2006 Dr. Dombeck wrote an excellent essay about "Boundaries and the Dysfunctional Family ." If you have not yet read this essay I highly recommend it especially as the present web log refers back to the issue of boundaries.
One of the observations I have made during the many years I have been seeing clients with eating disorders is that they often come from families with serious boundary problems. Salvador Minuchin referred to this boundary issue as enmeshment.
As Dr. Dombeck points out, boundaries are barriers and, for human beings these barriers exist as ideas that allow us to distinguish self from non self. Therefore, these boundaries are not actually visible but exist as psychological constructs.
In families, there are important boundaries that are generational in nature. In other words, there are boundaries between children and parents. If a family is functioning in ways that are healthy then the boundaries between parents are children are flexible, Flexibility means that there is the right amount of authority in the hands of parents to allow for the guidance, socialization and education of the children. At the same time flexibility permits parents to allow children the experience of age appropriate autonomy so that they can grow in self confidence as they learn to function outside of the home.
A dysfunctional family is either: one in which the children are granted too much autonomy for their age and are, in reality, neglected, or: one in which parents and children become enmeshed so that boundary lines are violated.
Case studies in the field of eating disorders as well as my own observations show that eating disordered patients tend to come from families that are extremely enmeshed with the result that the sense of autonomy, individuality and independence has not been established by adolescence and young adulthood, especially for females. It is for this reason that the treatment of young women with eating disorders includes family therapy in order to address the problem of enmeshment.
Clinical Examples of Enmeshment:
These are fictionalized examples of the types of boundary problems I have observed:
A young woman wants very much to please her parents. Both mother and father are accountants. Therefore, instead of taking the premedical course of study that she wanted during her college years, she studied accounting, went to graduate school and became a certified accountant earning an excellent living at a large business firm. However, she suffered from a mixed type of anorexia-bulimia but insisted there was nothing wrong with her. She hated her career but would not admit to any anger at either of her parents. Her parents purchased her a condominium, selected the furnishings and art work for her and came to visit each weekend, stocking her refrigerator with food of their choosing. They never knew how little of the food she actually ate.
During her childhood a young woman’s parents purchased a large television set for the family and placed it in her room. In order to watch television, the entire family had to go to her room. When she was very young this strange arrangement did not seem to bother her. However, when she became pubescent and started to rebel she was upset by family member walking into her room to watch their programs. These family members included her parents, brother and sister.
To make matters even worse, her sister’s clothes were stored in her closet necessitating the need for the sister to further intrude into her privacy.
There was never any explanation for these strange arrangements. What is significant is the fact that this patient became bulimic during the early part of her adolescence. Her sister and brother each developed their own types of psychological disorders.
The last example is of a young woman who suffered from a case of anorexia that was serious enough for her to be hospitalized. Her extremely self centered parents were unforgiving of her for the hospitalization. They were convinced that she was being ungrateful to them for having raised her. In family meetings the father, who did not want to be there, was outraged by the inconvenience and cost this was putting him through. Her mother felt abandoned by her daughter’s hospitalization. It had always been the job of the daughter to care for her mother. Caring for this mother included listening to her mother’s complaints about her father’s poor sexual prowess. It never occurred to the mother that this was totally inappropriate information for her daughter to hear about. In fact, the mother discussed all the details of her unhappy marriage telling her daughter things that the mother should have been discussing with other adults.
Details Common to the Three Young Women:
In all three cases these patients had no sense of self. Specifically, this means that none of them had any idea of what career choices they wanted for themselves, what taste in music they preferred or what political issues were important to them.
Each one of the three felt totally responsible for the well being of their parents and would do nothing that they believed could cause hurt or disappointment. They would not express anger at either of their parents and all insisted that their parents did the best they could.
In each case the young women had parents, particularly mothers, who made decisions for them. These mothers never recognized the fact that their daughters were now adults and needed to make their own decisions. Interestingly, each one of these patients denied that there was anything wrong with their mother making these decisions.
All three had great difficulty making decisions regardless of whether they wee dealing with major or minor issues. For example, selecting a movie to go to was a daunting task. Most often they would tell whomever they were with that "anything would be fine."
In each of the cases the patients came to realize that restricting food was the only way they had of exerting some measure of control over their lives. However, this came only after a lot of hard therapeutic work.
Finally, in all three cases no one in the respective families noticed how thin their daughters were and all three families expressed surprise at learning about the eating disorder. It was only in case 3 that the parents expressed resentment at the diagnosis and at their daughter.
There are additional factors behind eating disorders in addition to enmeshed family dynamics. Among these are:
1. The emphasis on physical beauty being defined as being thin in all of the media that influence young adolescents.
2. Traditional role expectation that girls prepare themselves to be mothers who nurture others at the expense of themselves.
3. Despite all of the social changes that have occurred the emphasis continues to be on girls being passive and exerting their influence through sexual beauty and through being aggressive and assertive.
4. It is not simply that, for girls, the emphasis is on physical beauty being defined as being thin but on physical beauty as a vitally important trait if she wants to feel accepted.
In the United States, eating disorders begin to exert themselves among girls from as early as nine and ten years old. For many young women anorexia or bulimia is full blown by the time they are in Middle School. Surveys show that most college women have experimented with purging at least once.
What are your thoughts about Eating Disorders and Family Boundaries?
Keep Reading By Author Allan Schwartz, LCSW, Ph.D.
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