• Anorexia Nervosa is an eating disorder and, more importantly, a psychological disorder.
• The cause of anorexia has not been definitely established, but self-esteem and self-image issues, family dynamics, societal pressures, and even genetic factors may each play a role.
• Anorexia affects females far more often than males and is most common in adolescent females.
• The disorder affects about 1% of adolescent girls in the U.S.
• People with anorexia tend to show compulsive behaviors and may become obsessed with food.
• The extreme dieting and weight loss can lead to a potentially fatal degree of malnutrition.
• Other possible consequences of anorexia include heart-rhythm disturbances, digestive abnormalities, anemia, and hormonal and electrolyte imbalances.
• The treatment of anorexia must focus on more than just weight gain.
• The prognosis of anorexia is variable, with some people making a full recovery.  Others experience a fluctuating pattern of weight gain followed by a relapse, or a progressively deteriorating course over many years.
• As with many other addictions, it takes a day-to-day effort to control the urge to relapse, and treatment may be needed on a long-term basis.

Anorexia is among the psychiatric conditions with the highest mortality rate, with an estimated 6% of anorexia victims dying from complications of the disease.  The most common causes of death in people with anorexia are medical complications of the condition including cardiac arrest and electrolyte imbalances.  Suicide is also a cause of death in people with anorexia.
Early diagnosis and treatment can improve the overall prognosis in an individual with anorexia.  With appropriate treatment, about half of those affected will make a full recovery.  Some people experience a fluctuating pattern of weight gain followed by a relapse, while others experience a progressively deteriorating course of the illness over many years and still others never fully recover.  It is estimated that about 20% of people with anorexia remain chronically ill from the condition.
As with many other addictions, it takes a day-to-day effort to control the urge to relapse.  Many individuals will require ongoing treatment for anorexia over several years, and some may require treatment over their entire lifetime.

Anorexia may be treated in an outpatient setting, or hospitalization may be necessary.  For an individual with severe weight loss that has impaired organ function, hospital treatment must initially focus on correction of malnutrition, and intravenous feeding may be required.  A gain of between one to three pounds per week is a safe and attainable goal when malnutrition must be corrected.
The overall treatment of anorexia, however, must focus on more than weight gain.  There are a variety of treatment approaches dependent upon the resources available to the individual.  Because of increasing insurance restrictions, many patients find that a short hospitalization followed by a day treatment program is an effective alternative to longer inpatient programs.  Most individuals, however, initially seek outpatient treatment involving psychological as well as medical intervention.
Different kinds of psychological therapy have been employed to treat people with anorexia.  Individual therapy, cognitive behavior therapy, group therapy, and family therapy have all been successful in treatment of anorexia.  Those with anorexia can be treated by a medical doctor, a clinical psychologist, or both, depending upon the progression of the disorder.  A psychiatrist with both medical and psychological training is perhaps the best treatment provider.  An appropriate treatment approach addresses underlying issues of control and self-perception.  Family dynamics are explored, and often the family is included in the treatment plan.  Nutritional education provides a healthy alternative to weight management for the patient.  Group counseling or support groups often assist the individual in the recovery process.  The ultimate goal of treatment should be for the individual to accept herself/himself and lead a physically and emotionally healthy life.
While no medications have been identified that can definitively reduce the compulsion  too starve themselves, some of the selective serotonin reuptake inhibitor (SSR) antidepressant drugs have been shown to be helpful in weight maintenance after weight has been gained, and in controlling mood and anxiety symptoms that may  be associated with the condition.

• Kidney (renal) function may appear normal.  However, there are significant changes in kidney function in many people with anorexia, resulting in potassium deficiency, increased urination, or decreased urination.
• Anorexics who use a large quantity of laxatives or who frequently vomit are at great risk for electrolyte imbalance, which can have life-threatening consequences.
• Anemia is frequently found in anorexic patients.  Suppressed immunity and a high risk for infection are suspected, but not clinically proven.
• Physical symptoms, other than the obvious loss of weight, can also be seen.  Anorexia can cause dry, flaky skin that takes on a yellow tinge.  Fine, downy hair grows on the face, back, arms, and legs.  Despite this new hair growth, loss of hair on the head is not uncommon.  Nails can become brittle.  Frequent vomiting can erode dental enamel and eventually lead to tooth loss.

Most of the medical complications of anorexia nervosa result from starvation.  Few organs are spared the progressive deterioration brought about by anorexia.

• Heart and circulatory system: Although not life-threatening, an abnormally slow heart rate (bradycardia) and unusually low blood pressure (hypotension) are frequent manifestations of starvation and are commonly associated with anorexia.  Of greater significance are disturbances in the heart rhythm (arrhythmia).  A reduction in the work capacity of the heart is associated with severe weight loss and starvation.
• Gastrointestinal complications are also associated with anorexia.  Constipation and abdominal pain are the most common symptoms.  The rate at which food is absorbed into the body is slowed down.  Starvation and overuse of laxatives can seriously disrupt the body’s normal functions involved in the elimination process.  While liver function is generally found to be normal, there is evidence of changes in enzyme levels and overall damage to the liver.
• The glandular (endocrine) system in the body is profoundly affected by anorexia.  The complex physical and chemical processes involved in the maintenance of life can be disrupted, with serious consequences.  Disturbances in the menstrual cycle are frequent and can affect not only fertility but also bone density, which is very important to a woman’s health as she ages.  Hormonal imbalances are found in men with anorexia as well.  Continual restrictive eating can trick the thyroid into thinking that the body is starving, causing it to slow down in an attempt to preserve calories.

Next week we will continue to discuss the physical signs and symptoms of anorexia.

• Generally, individuals with anorexia are compliant.  Sometime, they are overly compliant, to the extent that they lack adequate self-perception.  They usually do well in school and may often overextend themselves in a variety of activities.  The families of anorexics often appear to be “perfect.”  Physical appearances are important to them.  Performance in other areas is stressed as well, and they are often high achievers.
• While control and perfection are critical issues for individuals with anorexia, aspects of their life other than their eating habits are often found to be out of control as well.  Many have, or have had at some point in their lives, addictions to alcohol, drugs, or gambling.  Compulsions involving sex, exercising, housework, and shopping are not uncommon.  In particular, people with anorexia often exercise compulsively to speed the weight-loss process.

All of these features can negatively affect one’s daily activities.  Diminished interest in previously preferred activities can result.  Some individuals also have symptoms that meet the diagnostic criteria for a major depressive disorder.

Anorexia can have dangerous psychological and behavioral effects on all aspects of an individual’s life and can affect other family members as well. Signs and symptoms include:

• The individual can become seriously underweight, which can lead to depression and social withdrawal.
• The individual can become irritable and easily upset and have difficulty interacting with others.
• Sleep can become disrupted and lead to fatigue during the day.
• Attention and concentration can decrease.
• Most individuals with anorexia become obsessed with food and thoughts of food.  They think about it constantly and become compulsive about eating rituals.  They may collect recipes, cut their food into tiny pieces, prepare elaborate calorie-laden meals for other people, or hoard food.  Additionally, they may exhibit other obsessions and/or compulsions related to food, weight, or body shape that meet the diagnostic criteria for an obsessive compulsive disorder.
• Other psychiatric problems are also common in people with anorexia nervosa, including affective (mood) disorders, anxiety disorders, and personality disorders.  (to be continued next week)

There are four basic criteria for the diagnosis of Anorexia Nervosa that are characteristic:

1. The refusal to maintain body weight at or above a minimally normal weight for age and height.  Body weight less than 85% of the expected weight is considered minimal.
2. An intense fear of gaining weight or becoming fat, even though the person is underweight.
3. Self-perception that is grossly distorted and weight loss that is not acknowledged.
4. In women who have already begun their menstrual cycle, at least three consecutive periods are missed (amenorrhea), or menstrual periods occur only after a hormone is administered.

The DSM-IV further identifies two subtypes of Anorexia Nervosa.  In the binge-eating/purging type, the individual regularly engages in binge eating or purging behavior which involves self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode of anorexia.  In the restricting type, the individual severely restricts food intake but does not engage in the behaviors seen in the binge eating type.

Anorexia nervosa is a complicated disorder to diagnose.  Individuals with anorexia often attempt to hide the disorder.  Denial and secrecy frequently accompany other symptoms.  It is unusual for an individual with anorexia to seek professional help because the individual typically does not accept that she or he has a problem (denial).  In many cases, the actual diagnosis is not made until there are other medical complications.  The individual is often brought to the attention of a professional by family members only after  a marked weight loss has occurred.  When anorexia finally comes to the attention of the health professional, they often lack insight into their problem despite being severely malnourished and may be unreliable in terms of providing accurate information.  Therefore, it is often necessary to obtain information from parents or other family members in order to evaluate the degree of weight loss and extent of the disorder.

The actual criteria for anorexia nervosa are found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

At this time, no definite cause of anorexia nervosa has been determined.  However, research within the medical and psychological fields continues to explore possible causes.

Some experts feel that demands from society and families could possibly be underlying causes for anorexia.  For many individuals with anorexia, the destructive cycle begins with the pressure to be thin and attractive.  A poor self-image compounds the problem.

Other researchers feel that this disorder can stem from a particular dysfunction often seen in families of anorexia patients.  In one particular type of dysfunction, family members become so interdependent that each cannot achieve their identity as an individual.  Thus, family members are unable to function as healthy individuals and are dependent on other family members for their identity.  In children, part of this dysfunction includes a fear of growing up (especially girls).  Restrictive dieting may prevent their bodies from developing in a normal manner, and in their thinking, restricts the maturational process and maintain the parent-child relationship that the family has come to rely on.  Other family situations that been suggested, but not proven, as possibly being related to the development of anorexia nervosa include: high parental expectations, poor communication skills, and problems with conflict management.

Some studies suggest that a genetic (inherited) component may play a role in determining a person’s susceptibility to anorexia.  Researchers are currently attempting to identify the particular gene or genes that might affect a person’s tendency to develop this disorder.