Introduction
Anorexia nervosa was described first by Richard Morton in 1689 as “nervous consumption caused by sadness, and anxious cares” (Levey, Williams-Wilson, Curfman, 2006). The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-1V), has defined anorexia nervosa as “the refusal to maintain body weight about 85% of predicted, an intense fear of gaining weight, undue influence of body shape or weight on self image, and missing at least 3 consecutive menstrual periods” (Liburd, 2006). All organ systems might be affected by anorexia nervosa; however, the principal systems that are affected include the cardiovascular and the endocrine systems. Complications affecting other systems like gastrointestinal, renal, reproductive, neurologic, orofacial, and hematologic, may also be noted (Liburd, 2006).
Anorexia nervosa may be more common among certain groups, where there is an excessive emphasis, requirement, and appreciation on being thin. These groups include: dancers, skaters, models, actors, flight attendants, college sorority members etc. (Liburd, 2006). There are 2 subtypes of anorexia nervosa: binge-eating/purging type and the restricting type. In the binge-eating/purging type, the individual demonstrates binge-eating or purging behavior on a regular basis. This may be in the form of self-induced vomiting, or by the misuse of laxatives, diuretics, or enemas (Levey, Williams-Wilson, Curfman, 2006). When compared to the restricting type, they are more likely to have problems with substance use, emotional lability, and sexual activity. They also are more likely to have had the illness for a longer time, and are more heavier (Levey, Williams-Wilson, Curfman, 2006).
In the restricting type, there is no binge-eating or purging; the individual tries to lose weight mainly by fasting, dieting, or excessive exercise. In this type, the individual is more likely to be more obsessional, more awkward socially, and more isolated, when compared to those with the binge-eating/purging type (Levey, Williams-Wilson, Curfman, 2006).
Anorexia nervosa may be divided into 2 stages: an early or mild stage and an established stage (Liburd, 2006). The early or mild stage is characterized by: mildly distorted body image, 90% or less of average weight for height, absence of signs or symptoms of excessive weight loss, and the use of potentially harmful weight-control methods or a strong drive to lose weight (Liburd, 2006). The established stage is characterized by: definite distortion of body image, less than 85% of average weight for height and a refusal to gain weight, symptoms or signs of excessive weight loss, denial that any problems exists, and adoption of unhealthy means of losing weight like eating less than 1000 calories per day, purging, or excessive exercise (Liburd, 2006).
Anorexia nervosa may also be associated with other disorders like depression, social withdrawal, irritability, insomnia, decreased libido and obsessive-compulsive features related to and unrelated to food. Additionally, there might be concern about eating in public, feeling of worthlessness, urge to control one’s environment, inflexibility in thinking, lack of spontaneity etc. (Levey, Williams-Wilson, Curfman, 2006).
Anorexia nervosa is more common in the industrialized countries, where being thin is considered to be more attractive, and is more frequent in Whites than the nonwhite populations (Levey, Williams-Wilson, Curfman, 2006).
The frequency of anorexia nervosa in the U.S is around 1 out of 100-200 females, while internationally, the rate of anorexia nervosa is similar in all developed countries (Levey, Williams-Wilson, Curfman, 2006).
Although this condition is more common in females (90%), it is not uncommon in males (10%) (Levey, Williams-Wilson, Curfman, 2006). Anorexia nervosa is commonly encountered between early adolescence (13-18 years) and early adulthood but an early or late onset can also occur (Levey, Williams-Wilson, Curfman, 2006).
Causes
There are certain predisposing factors, which makes a person predisposed to developing anorexia. These include: female sex, family history of eating disorders, being a perfectionist, difficulty in communicating negative emotions, difficulty in resolving conflict, and low self-esteem (Liburd, 2006). There are also precipitating factors in the development of anorexia. In the age group of 10-14 years, it is related to sexual development and menarche (which is associated with a spurt in weight gain) (Liburd, 2006). In the age group of 15-16 years, it is related to issues of independence and autonomy (Liburd, 2006). In the age group of 17-18 years, identity conflicts can occur and the individual might not make a healthy transition during leaving home, going to college or getting married (Liburd, 2006).
A combination of genetic, neuroendocrine, physiological, and psychosociological influences play a role in the etiology of anorexia nervosa.
- Genetic: studies conducted on twins have shown that this condition might run in families. However, the specific genetic factors have not yet been identified (Levey, Williams-Wilson, Curfman, 2006)
- Neuroendocrine: two hypotheses have been put forward to explain anorexia. The hypothalamic abnormality hypothesis postulates that hypothalamic abnormalities (e.g., neurotransmitter disturbances) lead to anorexia but this has not been proved (Levey, Williams-Wilson, Curfman, 2006). Another hypothesis called the starvation hypothesis postulates that starvation leads to abnormal hormone and neurotransmitter regulation, leading to anorexia (Levey, Williams-Wilson, Curfman, 2006) Patients who have recovered from anorexia have also demonstrated abnormalities in 5-hydroxytryptamine (5-HT), noradrenaline, and corticotropic-releasing hormone (CRH) function (Levey, Williams-Wilson, Curfman, 2006)
- Physiological: several hypotheses have been put forward that suggest that there are some physiological alterations in persons who are anorectic, which might help to sustain the fasting state (Levey, Williams-Wilson, Curfman, 2006). These physiological alterations include: delayed gastric emptying and different levels of cholecystokinin (CCK) when compared to normal individuals (Levey, Williams-Wilson, Curfman, 2006.)
- Psychological: it has been suggested that a variety of psychological, sociological, and family influences might play a role in the etiology of anorexia nervosa (Levey, Williams-Wilson, Curfman, 2006.)
According to psychodynamic theories, anorexia may be due to “a failure to separate, individuate, and develop autonomy from the primary caregivers”(Levey, Williams-Wilson, Curfman, 2006.)
Due to cultural changes, women might have favored autonomy and independence instead of relationships, which leads to eating disorders like anorexia (Levey, Williams-Wilson, Curfman, 2006.)
An anorectic “by rejecting symbolic parts of her body”(Levey, Williams-Wilson, Curfman, 2006) tries to conform to the existing cultural norms. Other theories include the self-psychology theory put forward by Geist, the psychoanalytic theory, and the family theories (Levey, Williams-Wilson, Curfman, 2006.)
According to the psychoanalytic theory, the symptoms of anorexia are a defense, which serves to mask the “underlying core set of more primitive issues and dynamics”(Levey, Williams-Wilson, Curfman, 2006). The fear and resistance to growing up is one such central issue (Levey, Williams-Wilson, Curfman, 2006.)
According to the family theories, anorectic symptoms are used by the patient as a “cry for help for a conflicted and dysfunctional family”(Levey, Williams-Wilson, Curfman, 2006.)
Families of anorectics have been described as being enmeshed, and shifting between overprotectiveness to abandonment (Levey, Williams-Wilson, Curfman, 2006). While the care of the anorectic child helped to ease parental conflicts, the balance of the family gets disturbed as soon as the same child matured (Levey, Williams-Wilson, Curfman, 2006.)
The cognitive-behavioral theories postulate that anorexia is a “learned behavior maintained by positive reinforcement”(Levey, Williams-Wilson, Curfman, 2006). Since being overweight invokes negative reinforcement, disapproval, and even ridicule, the anorectic diets excessively to lose weight (Levey, Williams-Wilson, Curfman, 2006). This is later reinforced by the subject’s peers and society. The anorectic might have such a strong reinforcement that the anorexic behavior is maintained, inspite of deteriorating health (Levey, Williams-Wilson, Curfman, 2006.)
Media influences play a major role in the etiology of anorexia. Being slim is considered fashionable by books, magazines, fashion industry and the television and film industry (Levey, Williams-Wilson, Curfman, 2006). There is an emphasis on physical fitness and athleticism (Levey, Williams-Wilson, Curfman, 2006.)
How anorexia affects development over the lifespan
In the adolescent age group, potentially irreversible medical complications like growth retardation can occur if the onset of anorexia occurs before epiphyseal closure (Adolescent Medicine Committee, 1998).
Numerous hormonal changes play a role in the growth retardation seen in anorexia; these include: low triiodothyronine (T3), low thyroxine (T4), elevated cortisol, and low sex hormone levels. In addition, growth hormone resistance (growth hormone hypersecretion and low serum levels of growth hormone-binding protein), insulin-like growth factor I, and insulin-like growth factor-binding protein 3 have also been implicated in the growth failure in anorexia (Modan-Moses et al., 2003).
Other complications that can occur include delay or arrest of puberty. During the second decade of life, there might be an impaired acquisition of peak bone mass (Adolescent Medicine Committee, 1998).
Osteopenia is a serious complication in which both cortical and trabecular bone is affected (Soyka et al., 2002). In adulthood, there is an increased risk of development of osteoporosis (Adolescent Medicine Committee, 1998). Bone fractures can occur. Brachial fractures may occur at around the age of 24 years, vertebral fractures at around the age of 25 years and pelvic fractures at around the age of 38 years (Tsuboi, 2005).
Amenorrhea occurs due to disordered hypothalamic-pituitary-ovarian axis and subsequent low levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) (Adolescent Medicine Committee, 1998). This can cause a reversal to the prepubertal state. In the reproductive age group, there occurs a reduction in fertility, multiple small follicles in the ovaries, and decreased uterine volume and atrophy (Adolescent Medicine Committee, 1998).
Anorexia Nervosa has an unpredictable course, and the condition can be precipitated by stressful events. While an acute course is seen in some, others follow a more chronic course, characterized by fluctuating weight loss and gain, relapse, and increasing health problems. Many patients with the restricting subtype of anorexia might shift to the binge-eating/ purging subtype, within the first 5 years.
Untreated cases might require hospitalization due to severe dehydration and electrolyte imbalance. While the prognosis is better with an earlier adolescent onset, the recovery rates are low. The prognosis is also better when there is a good relationship between the parent and child (Liburd, 2006). The prognosis is guarded or bad if there is a long duration of illness, late onset of illness, and more severe weight loss (Liburd, 2006).
Approximately 10% of cases recover fully from anorexia, whereas 50% recover only partially (Wilmshurst, 2005). The mortality rate due to anorexia is around 6-20%, and death is usually secondary to starvation, suicide, electrolyte imbalance, or infections (Levey, Williams-Wilson, Curfman, 2006).
Conclusion
Anorexia is an eating disorder characterized by the refusal to maintain body weight, an intense fear of gaining weight, undue concern of body shape or weight on self image, and missing at least 3 consecutive menstrual periods. There are 2 subtypes of anorexia nervosa: binge-eating/purging type and the restricting type, and are of two types, an early or mild stage and an established stage.
The etiology of anorexia nervosa includes a combination of genetic, neuroendocrine, physiological, and psychosociological influences. Anorexia affects development by causing growth retardation, amenorrhea and delay or arrest of puberty in the adolescent, and osteopenia, osteoporosis and bone fractures in adults. Untreated cases might develop severe dehydration and electrolyte imbalance. The prognosis is better with an earlier adolescent onset, while the prognosis is guarded or bad with a longer duration of illness, late onset of illness, and more severe weight loss. The mortality rate due to anorexia is around 6-20%, and death may occur due to starvation, suicide, electrolyte imbalance, or infections.
References
Adolescent Medicine Committee (1998). Eating disorders in adolescents: Principles of diagnosis and treatment. Paediatrics & Child Health.3(3):189-92.
Levey, R, Williams-Wilson, B, Curfman, WC (2006). Anorexia. Emedicine. Web.
Liburd, JDA (2006). Eating Disorder: Anorexia. Emedicine.
Modan-Moses, D, Yaroslavsky, A, Novikov, I, Segev, S, Toledano, A, Miterany, E, Stein, D (2003). Stunting of Growth as a Major Feature of Anorexia Nervosa in Male Adolescents. Pediatrics. 111(2) : 270-276.
Soyka, LA, Misra, M, Frenchman, A, Miller, KK , Grinspoon, S, Schoenfeld, DA, Klibanski, A (2002). Abnormal bone mineral accrual in adolescent girls with
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Tsuboi, K (2005). Eating Disorders in Adolescence and Their Implications. JMAJ. 48(3): 123–129.
Wilmshurst, L (2005). Essentials of Child Psychopathology. Hoboken, NJ, USA: John Wiley & Sons, Incorporated. p 157.